capeintegrativehealth.com - Patient Registration and History

PATIENT REGISTRATION AND HISTORY
HIPAA FORM (YOUR HEALTH INFORMATION RIGHTS):
Cape Integrative Health has designated a Privacy Specialist to answer questions regarding our Privacy Practices as well as to respond to information requests or complaints. You may contact the Privacy Specialist by calling us at 207.799.9950. For inquiries that require a written request, please address them to: Cape Integrative Health 8-10 Hill Way Cape Elizabeth, ME 04107. Attention: Privacy Specialist

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION (PHI):
- OBTAIN A PAPER COPY OF THE NOTICE UPON REQUEST: At any time, you may request a paper copy of the Notice. Even if you have agreed to receive the notice electronically, you are still entitled to a paper copy, you may request one in person or by contactingthe Privacy Specialist.
- REQUEST A RESTRICTION ON CERTAIN USES AND DISCLOSURES OF YOUR PHI. You have the right to request additional restrictions on our use or disclosure of your PHI by sending a written request to our Privacy Specialist (address listed above).
- INSPECT AND OBTAIN A COPY OF PHI. You have the right to review and copy your PHI which will be kept in a designated record setting for as long as legally required by the State of Maine. The “designated record set” usually will include care and billing records. To review or copy your PHI, you must send a written request to our Privacy Specialist (address listed above). We may charge you a reasonable fee for the costs of copying, mailing, or other supplies that are necessary to grant your request. In certain circumstances we may deny your request to review and copy. If you are denied access to your PHI, you may request that the denial be reviewed.
- REQUEST AND AMENDMENT OF PHI. If you feel your PHI, that we maintain is in complete or incorrect, you may request that we amend it. You may request an amendment for as long as we maintain your PHI. To request amendment, you must send a written request to the Privacy Specialist (address listed above). You must include a reason that supports your request. In certain cases, we may deny your request for the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give you a rebuttal to your statement.
- RECEIVE A REPORT OF THE DISCLOSURE OF PHI. You have the right to receive a report of the disclosures we have made to your PHI. The report will exclude disclosures we have made directly to you, disclosures to friends or family members involved in your care, and disclosure for notification purposes. The right to receive a report is subject to certain other exceptions, restrictions, and limitations. To request a report, you must submit your request in writing to our Privacy Specialist (address listed above). Your request must specify the time period but may not be longer than six years. The first report you request within a 12-month period will be free of charge, but you may be charged for the cost of providing additional reports there after. We will notify you of the cost involved and you may choose to withdraw or modify your request at any time.
- REQUEST COMMUNICATIONS OF PHI BY ALTERNATIVE MEANS OR ALTERNATIVE LOCATIONS. For instance, you may request that we contact you about Health matters only in writing or at a different residence or post office box. To request a confidential communication of PHI about you, you must submit your request to the Privacy Specialist (address listed above). You request must state how or when you would like to be contacted. We will accommodate all reasonable requests.
FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions or would like additional information about the Clinic’s Privacy Practices, you may contact our Privacy Specialist at 207.799.9950 or send an e-mail to info@capeintegrativehealth.com. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Specialist or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint. By signing below, I acknowledge that I have received a paper copy of this Notice of Privacy Practices. I have read this notice and had an opportunity to ask questions regarding all of the above listed Privacy Practices.
Patient/Patient Representative’s Signature

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Date of Signature

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Patient/Patient Representative’s Name (Printed)

AUTHORIZATION & CONSENT FOR TREATMENT:
I hereby request and consent to the administration of treatment at Cape Integrative Health, including (but not limited to): primary care, chiropractic adjustments and procedures, various modes of physical therapy, various modes of acupuncture, and if necessary, diagnostic x-rays and blood work for myself (or for the patient named here for whom I am legally responsible: * ) by the attending provider and/or anyone working in this office authorized by the provider.

I further understand that such services may be performed by providers and authorized employees of Cape Integrative Health who may treat me now or in the future at this office. I have had an opportunity to discuss the mentioned procedures with a staff member of Cape Integrative Health and understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine and all healthcare, various procedures may carry some rare risks to treatment. Those risks include but are not limited to: fractures, disc injuries, strokes (CVA), dislocations, pneumothorax, bruising, bleeding, and sprains. Further, I wish to rely on the provider to exercise judgment during the course of treatment which the provider feels are in my best interests at this time, based upon the facts then known.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by the provider. I intend this consent form to cover the entire course of treatment at this facility for my present condition(s) and for any condition(s) for which I will seek treatment in the future.
Patient/Patient Representative’s Signature

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Date of Signature

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Patient/Patient Representative’s Name (Printed)

CONSENT TO TREAT A MINOR:
I/we, the undersigned parent(s)/person(s), having legal custody/legal guardianship of Type a label , a minor, do hereby authorize Cape Integrative Health as agent(s) for the undersigned to consent to: any x-ray examination, blood work, chiropractic diagnosis/treatment, acupuncture diagnosis/treatment and/or physical therapy diagnosis/treatment, which is deemed advisable and administered under the general or special supervision of any Cape Integrative Health authorized primary care provider, licensed chiropractor, licensed acupuncturist or licensed physical therapist.

It is understood that this authorization is given in advance of any specific diagnoses or treatments being required but that such authorization is given to provide authority to the above described agent(s) to give specific consent to any and all such diagnoses and treatments which the primary care provider, chiropractor, acupuncturist and/or physical therapist meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable.
Date:

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Signature: (parent/legal guardian/person having legal custody)

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CANCELLATION POLICY
Your appointment is very important to all members of the Cape Integrative Health Team. The time allocated for your appointment has been set aside just for you.

We understand that events might arise resulting in the need to cancel or reschedule an appointment. If it becomes necessary to reschedule or cancel an existing appointment, we request that you provide the office with at least 24 hours notice. This will allow us time to potentially schedule another patient in that time slot.

For no-shows or cancellations taking place less than 24 hours from the time of an appointment, there will be a $95 fee assessed to the patient.

All Monday appointments must be cancelled by the prior Friday as the Office will be closed on the weekends.

By signing below, you acknowledge our cancellation policy and agree to abide by it. Thank you!
Patient Signature

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Date

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PATIENT INFORMATION
TODAY’S DATE

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Sex/Gender (choose one)

MaleFemaleOther
Age
D.O.B.

MonthDayYear
Date
Height
Weight
Your Occupation
Employer/School
Employer/School Address
Hobbies/Interests
Dietary Restrictions, if any:
Does your diet include:

GlutenSugarDairy
If Married/Partnered, Spouse/Partner’s Name
If Married/Partnered, Spouse/Partner’s D.O.B.

MonthDayYear
Date
If Married/Partnered, Spouse/Partner’s Employer
Emergency Contact:
Relationship:
Emergency Contact Phone Number:
Please enter a valid phone number.
PATIENT PHONE PERMISSIONS
Please indicate what information we may leave on your cell phone’s voicemail:

Detailed messages regarding appointments, medical treatment, care, test results, or financial informationOnly general messages regarding appointments (confirmations or cancellations)

	F	M	S	B	GF	GM
Asthma
Heart Attack
Kidney Disease
Parkinson's
Thyroid Problems
Cancer
Heart Disease
Liver Disease
Rheumatoid Arthritis
Dementia
High Blood Pressure
Miscarriage
Seizures
Diabetes
High Cholesterol
Osteoporosis
Stroke

PATIENT REGISTRATION AND HISTORY

AUTHORIZATION & CONSENT FOR TREATMENT:

CONSENT TO TREAT A MINOR:

CANCELLATION POLICY

PATIENT INFORMATION

PATIENT PHONE PERMISSIONS

REFERRAL INFORMATION

PRIMARY CARE PROVIDER AND/OR OTHER PROVIDERS

AUTHORIZATION FOR RELEASE OF INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

PATIENT CONDITION

CAUSATION

FAMILY HISTORY