NEW PATIENT INTAKE FORM

TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you, As another example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

HEALTHCARE OPERATIONS: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as needed, to contact you to remind you of your appointment.

USE REQUIRED BY LAW: We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health Issues as required by law, Communicable Diseases: Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors; and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Worker’s Compensation; Inmates. Under the law, we must make disclosures to you and when, required by the Secretary of the Department of Health and Human Services.

 

YOUR RIGHTS
The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information: Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your healthcare provider is not required to agree to a restriction that you may request. If the healthcare provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
You have a right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes.
You then have the right to object or withdraw as provided in this notice.
You may have the right to have your healthcare provider amend your protected health information.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our office of your complaint. We will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with out HIPAA Compliance Officer listed below in person or by phone/email:

Dr. Mithun Sivadasan   732-790-5599   info@axispodiatry.com  

I do hereby seek and consent to take part in the treatment by the podiatrists at Axis Foot & Ankle. If the patient is a minor, I hereby give my consent as a parent/legal guardian for my child to be treated by the podiatrists at Axis Foot & Ankle. Consent for treatment with a child under the age of 18 years old must be provided by either parent. Exception is sole custody in which case documentation must be provided and placed into file.

RELEASE OF MEDICAL RECORDS: I authorize Axis Foot & Ankle to disclose medical records and other necessary health information to my referring physician, primary care physician, other healthcare providers, insurance carriers, or entities involved in my treatment, payment, or healthcare operations, as permitted under HIPAA. I acknowledge that I have been offered a copy of the Notice of Privacy Practices.

PAYMENT: I understand that insurance verification is not a guarantee of payment or coverage by my insurance carrier. I agree to pay all patient-responsibility amounts, including copayments, coinsurance, deductibles, non-covered services, and durable medical equipment dispensed during my visit, including but not limited to ankle braces, walking boots, and night splints. Axis Foot & Ankle will bill all contracted insurance carriers. Any remaining balance determined by my insurance carrier according to my plan benefits and contracted fee schedule will be my responsibility. I understand that it is my responsibility to verify my individual insurance benefits, deductible status, and coverage for procedures or durable medical equipment prior to my appointment. For your convenience, we accept most major credit cards and debit cards. Card transactions may be subject to a processing fee where permitted by law. I understand that accounts with unpaid balances will be referred to an outside collection agency if payment is not received within 120 days of the date of service. Prior to referral, at least one additional notice may be provided by phone call, voicemail, text message, or email.

SERVICES: By signing below, you authorize our office to submit specimens to pathology and/or microbiology laboratories for analysis and culture when medically necessary. These services are processed through your insurance by third-party laboratories, including providers such as Labcorp and Bako Diagnostics. Depending on your insurance coverage and benefits, you may receive a separate bill from the laboratory for any balance not covered by your insurance plan.

COMMUNICATIONS: I consent to receive phone calls, text messages, and voicemails regarding appointments, treatment coordination, and account balances at the phone numbers provided. Automated calling or texting systems may be used. Frequency of communications may vary.