sharandimd.com - New Patient Form

PATIENT REGISTRATION FORM
Today's Date:

MonthDayYear
Date
Clinic Name:
PATIENT INFORMATION

(Please use full legal name, no nicknames)
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #:
Please enter a valid phone number.
Social Security #:
Date of Birth:

MonthDayYear
Date
Age:
Sex:
Marital Status:
Drivers License#:
Employer Name:
Employer Address:
Work Phone #:
Please enter a valid phone number.
E-mail Address:
example@example.com
Cell Phone #:
Please enter a valid phone number.
Emergency Contact Name:
Emergency Phone #:
Please enter a valid phone number.
Please tell us how you heard about us:
Referred by:
GUARANTOR INFORMATION

(List person or insured name responsible for bill - use full legal name, no nicknames)
Relationship of Guarantor to Patient:

SelfSpouseParentOther
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #:
Please enter a valid phone number.
Social Security #:
Date of birth:

MonthDayYear
Date
Age:
Sex:

MaleFemale
Employer Name and Address:
Work Phone #:
Please enter a valid phone number.
INSURANCE INFORMATION

(Please allow receptionist to photocopy your insurance ID cards)
IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS
PRIMARY INSURANCE:
Plan Name:
Insured's Name:
Insured's Social Security #:
Insured's Date of Birth:

MonthDayYear
Date
Policy/ID #:
Group #:
Eff Date:

MonthDayYear
Date
Claims Address & Phone:
SECONDARY INSURANCE:
Plan Name:
Insured's Name:
Insured's Social Security #:
Insured's Date of Birth:

MonthDayYear
Date
Policy/ID #:
Group #:
Eff Date:

MonthDayYear
Date
Claims Address & Phone:

WEST PLANO MEDICAL ASSOCIATES

SAFOORA “SOPHIE” HARANDI, M.D.
Your Information. Your Rights. Our Responsibilities.

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.

Your Rights
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Your Choices

You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds
Our Uses and Disclosures

We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
- Choose someone to act for you.
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page l.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan, so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety
Do research
We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice
- Effective Date June 2013
- Privacy Officer: Dr Safoora Harandi
- reception@sharandimd.com
- (972) 312-8429
- We never market or sell personal information
- We will never release records pertaining to sensitive subject matter including: Mental Health Records, Substance Abuse Records, Genetic Information, or HIV/AIDS Tests Results/Treatment, without additional consent from you.
PATIENT SIGNATURE:

Clear
DATE:

MonthDayYear
Date

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO FAMILY MEMBERS OR PATIENT DESIGNATED TRANSLATOR
Patient Name:
Date of Birth:

MonthDayYear
Date
Many of our patients allow family members such as their spouse, parents or others to request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below. I authorize West Plano Medical Associates to release my medical and/or billing information to the following person(s):
PATIENT INFORMATION:

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed.

I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient.

You have the right to revoke this consent in writing.
Signature:

Clear
Date:

MonthDayYear
Date

	YES	NO
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals (nickel, gold, silver)
latex

	YES	NO
3. heart problems, or cardiac stent within the last six months
4. history of infective endocarditis
5. artificial heart valve, repaired heart defect (PFO)
6. pacemaker or implantable defibrillator
7. artificial prosthesis (heart valve or joints)
8. rheumatic or scarlet fever
9. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes
24. stomach or duodenal ulcer
25. digestive disorders (i.e. celiac disease, gastric reflux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthritis, rheumatoid arthritis, lupus
28. glaucoma
29. contact lenses
30. head or neck injuries
31. epilepsy, convulsions (seizures)
32. neurologic disorders (ADD/ADHD, prion disease)
33. viral infections and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. STI / STD
37. hepatitis
38. HIV / AIDS
39. tumor, abnormal growth
40. radiation therapy
41. chemotherapy, immunosuppressive
42. emotional problems
43. psychiatric treatment
44. antidepressant medication
45. alcohol / street drug use

	YES	NO
Service Quality
46. presently being treated for any other illness
47. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
48. taking medication for weight management (i.e. fen-phen)
49. taking dietary supplements
50. often exhausted or fatigued
51. experiencing frequent headaches
52. a smoker, smoked previously or use smokeless tobacco
53. considered a touchy person
54. often unhappy or depressed
55. FEMALE - taking birth control pills
56. FEMALE - pregnant
57. MALE - prostate disorders

PATIENT REGISTRATION FORM

PATIENT INFORMATION

GUARANTOR INFORMATION

INSURANCE INFORMATION

PRIMARY INSURANCE:

SECONDARY INSURANCE:

WPMA MEDICAL HISTORY

WEST PLANO MEDICAL ASSOCIATES

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO FAMILY MEMBERS OR PATIENT DESIGNATED TRANSLATOR

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION