Yarmouth Medical Center Patient Registration

I hereby give Yarmouth Medical Center my consent for any necessary and other health plans to Yarmouth Medical Center. A photo copy of this medical evaluation and treatment. I hereby assign all medical/surgical benefits to include major medical benefits to which I am entitled including Medicare, private insurance assignment is to be considered as valid as original. I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize said assign to release all information necessary to secure payment.

CONTROLLED SUBSTANCE DISCLOSURE: Yarmouth Medical Center does not prescribe chronic pain medication. We also do not prescribe Suboxone or Methadone. By signing below you indicate that you understand this policy and attest to the truthfulness of the information provided above.

Please Mail or fax records pertaining to the patient identified to: 

YARMOUTH MEDICAL CENTER

21 Aaron's Way, Unit 2, W. yarmouth, MA 02673

Phone: 508-760-2054

Fax: 508-760-1218

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONDIFENTIAL HIV* RELATED INFORMATION only if I place my initals on the appropriate line. In the event the health information described below includes any of these types of information, I initial the linke on the box, I specifically authorize release of such information to the person indicated

2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. 

3. I have the right to revoke this authorization at any tume by writing to Yarmouth Medical Center. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 

4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment at Yarmouth Medical Center, or eligibility benefits will not be conditioned upon my authorization of disclosure.

5. Information disclosed under this authorization might be redisclosed by redisclosed by the recipient (except as noted in #2 above), and this redisclosure may no longer br protected by feferal or state law. 

Include: (please indicate by initialing below):

This authorization will be in effect for one year from the date signed, unless you indicate a shorter period below:

All items on this form have been completed and my questions about this form have been answered. A copy of this form will be emailed to you, please keep it for your records.

I hereby authorize Yarmouth Medical Center to disclose information contained in my medical record to the individual(s) listed below, if they request it. I understand that when information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and no longer considered protected health information (PHI). I understand that I can revoke this authorization, in writing, at any time.

Our providers may discuss your PHI as authorized above. The individuals listed cannot receive copies of any information from your medical record without your written consent. If there is no one we can communicate with, please write ‘no one’ in each space provided.

The following individuals are authorized to pick up prescriptions, letters, or forms for me at the office. If there is no one, please write ‘no one’ in each space provided. You may write ‘same as above’ in the first space provided if individuals are the same.

Thank you for establishing care with Yarmouth Medical Center. To better serve you, we are providing a description of visit “types” to optimally accommodate your medical needs:

New Patient: This is a visit to establish care with your new provider. It is an opportunity to get to know each other, discuss your health history and set up a plan for future care. During this visit urgent medial needs may be addressed, but a follow up visit may be necessary for more comprehensive care.

Annual Physical Exam: This is a routine check-up that you should have every year. During this visit, your provider will assess your overall health and screen for any issues that need to be addressed. These visits are partially administrative in nature and focus on health maintenance. Please note that if you have a health concern we need to prioritize, your medical team may need to change your visit to an Office Visit to thoroughly address that need.

Follow-Up: These are visits to check on the progress of a health issue you have been treated for or are currently being treated for. Your provider will ask you questions, perform an exam and make any necessary adjustments to your treatment plan. Please note, these visits are required every 3 months for any patients who are being prescribed controlled substances.

Office Visits: These are for health issues that are not life threatening but still need to be addressed by a provider, ie: a rash or sinus infection. We do our very best to schedule these visits on the same day or closely thereafter. If you are experiencing respiratory (cough, congestion, fever) or gastrointestinal (nausea, vomiting, diarrhea) symptoms, a virtual visit MAY be necessary to ensure the safety of our patients and staff.

Medicare Annual Wellness: These visits are scheduled 6 months after an Annual Physical exam for those patients on Medicare, per CMS guidelines. During this visit, your provider will review your health history, perform a physical exam and create a personalized prevention plan to help you stay healthy. Please note, a dedicated portion of this visit is administrative and reserved for collection health data for screening.

Transition of Care: These visits are for patients who have been discharged from an Emergency Room, Hospital or Nursing Facility to the outpatient community. During this appointment, our provider will review your medical history and any recent test results to make sure they have a complete understanding of your inpatient experience. They will also discuss any ongoing treatments or medication to make sure there are no gaps in your care. These visits are important because they help ensure a smooth and seamless transition in your medical care.

Chronic Care Management: Per CMS guidelines, we are required to check in with Medicare patients who are experiencing chronic health issues such as Diabetes and Heart Disease. This is accomplished through monthly phone calls from our off-site colleagues who will inquire about your health status and ask if you have any questions or issues you would like forwarded to the provider. These calls are considered a visit and are billed to Medicare and your secondary insurance. If you do not wish to receive these calls please let our office staff know, however, many patients find them very helpful with managing their chronic issues.

To provide a safe and healthy environment for staff, visitors, patients and their families, Yarmouth Medical Center expects visitors, patients and accompanying family members to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff. As a patient visiting our practice, please consider the following:

• If you have any questions about the care or our unhappy with the service received in our office, please contact our practice manager before you leave our office so that any clarifications about your care or the services you received can be addressed.

• Please communicate all issues that you wish to discuss with the doctor at the time your appointment is scheduled, so that an appropriate amount of time can be allotted. If you do not do this in advance, another visit may be necessary so that the doctor can give all patients the time and quality of care they deserve. • Questions about your billing can be addressed to SVS Service, see bill for contact information .

• Our practice follows a zero-tolerance policy for aggressive behavior directed by patients against our staff.

• Please be courteous with the use of your cell phone and other electronic devices. When interacting with any of our staff, please put your devices away. Set the ringer to vibrate before storing away.

• Adults are expected to supervise their children. The following behaviors are prohibited:

• Possessing firearms or any weapon

• Intimidating or harassing staff or other patients

• Making threats of violence through phone calls, letters, voicemail, email or other forms of written, verbal or electronic communication

• Physically assaulting or threatening to inflict bodily harm

• Making verbal threats to harm another individual or destroy property • Damaging business equipment or property

• Making menacing or derogatory gestures

• Making racial or cultural slurs or other derogatory remarks

If you are subjected to any of these behaviors or witness inappropriate behavior, please report to any staff member. Violators are subject to removal from the facility and/or discharge from the practice.