FORMULARIO DE REGISTRO

 

Recommendamos utilizar una computadora

 

• Si desea completar esto en la oficina, llegue 20 minutos antes.

• Gracias! Nos vemos pronto! Dr J & Staff

 

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¿Contacto adicional? (Madre o tutor para un paciente menor de 18 años.)

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Seguro de Salud
Seguro Primario

Seguro de Salud
Seguro Secundario

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Información del Médico

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Información Farmaceútica

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ALLERGIES (PLEASE SPECIFY ALL MEDICAL ALLERGIES)

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MEDICAMENTOS

¿ESTÁ TOMANDO MEDICAMENTOS ANTIcoagulantes?

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HISTORIA

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SECCIÓN 1: OPINIONES, FORMULARIOS O CARTAS LEGALES, DE ABOGADOS Y DE SEGUROS

El Dr. Jacobsen no desea decepcionarlo si su consulta tiene como objetivo, o al menos en parte, obtener información sobre alguna de las siguientes cuestiones: opiniones, peritajes médicos, testigos, cartas o documentos relacionados con reclamaciones legales, instrucciones de su abogado o la necesidad de documentación relacionada con lesiones o cirugías realizadas en otro lugar. Por favor, informe a nuestro personal antes de consultar con el Dr. Jacobsen para que puedan ayudarle a encontrar de inmediato un cirujano plástico alternativo para su consulta. JACOBSEN NO PARTICIPA NI INTERVENIRÁ EN ASUNTOS LEGALES, NI DURANTE NI DESPUÉS DE SU CONSULTA, Y NO SE COMUNICARÁ CON SUS REPRESENTANTES LEGALES SOBRE ESTOS ASUNTOS.

TARIFAS: USTED O SU ABOGADO PUEDEN SOLICITAR COPIAS DE SUS FOTOS/CD POR UN CARGO DE REPRODUCCIÓN DE $250.00. CON GUSTO, SE LE PROPORCIONARÁ UNA COPIA DE SU HISTORIAL MÉDICO A SU SOLICITUD PARA FINES LEGALES O MÉDICOS POR UN CARGO DE REPRODUCCIÓN DE $100.

FORMULARIO PARA COMPLETAR: DR. El Dr. Jacobsen y su personal no completarán formularios laborales ni de discapacidad hasta que usted sea nuestro valioso paciente, se haya sometido a una cirugía, sea amable con nuestro personal y complete todos los campos posibles. En ese caso, el Dr. Jacobsen completará la información médica y la firmará. No completaremos formularios completamente en blanco. Debe hacer todo lo posible por completar todo lo que pueda con anticipación.

Firme a continuación para indicar que comprende estas limitaciones de los servicios del Dr. Jacobsen.

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SECCIÓN 2: CONSENTIMIENTO PARA TOMAR FOTOGRAFÍAS

POR LA PRESENTE AUTORIZO AL DR. WILLIAM M. JACOBSEN Y/O A SUS ASOCIADOS O LICENCIATARIOS A TOMAR FOTOGRAFÍAS Y/O VIDEOS PREOPERATORIOS, INTRAOPERATORIOS Y POSTOPERATORIO. ESTAS FOTOGRAFÍAS SON IMPORTANTES PARA MI ATENCIÓN PACIENTE Y NECESARIAS PARA CUALQUIER PROCEDIMIENTO, TRATAMIENTO O CIRUGÍA REALIZADA POR EL DR. JACOBSEN. ENTIENDO QUE EL DR. JACOBSEN PROTEGERÁ MI PRIVACIDAD Y MANTENDRÁ ESTAS FOTOGRAFÍAS PRIVADAS Y SEGURAS COMO PARTE DE MI HISTORIAL MÉDICO. ENTIENDO QUE EL DR. JACOBSEN NO COMPARTIRÁ MIS FOTOGRAFÍAS NI LAS USARÁ PARA NINGÚN OTRO PROPÓSITO A MENOS QUE SE CONCEDA Y FIRME UN ACUERDO POR SEPARADO PARA MI PERMISO.

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SECCIÓN 3: CONSENTIMIENTO PARA NO TOMAR FOTOS EN LA OFICINA DEL DR. JACOBSEN

ACEPTO NO TOMAR FOTOS, VIDEOS NI GRABAR AL DR. JACOBSEN NI A SU OFICINA SIN SU PERMISO VERBAL PREVIO.

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SECCIÓN 4: ACUERDO DE EXPERTO EN NEGLIGENCIA

EL DR. JACOBSEN SE ENORGULLECE DE NUESTRA REPUTACIÓN POR BRINDAR ATENCIÓN QUIRÚRGICA DE LA MÁS ALTA CALIDAD A NUESTROS PACIENTES. SIN EMBARGO, NOSOTROS RECONOCEMOS QUE PUEDE HABER OCURRIR EN CASO DE QUE ALGUNOS PACIENTES NO ESTÉN SATISFECHOS CON LOS RESULTADOS DE SUS TRATAMIENTOS. TAMBIÉN RECONOCEMOS QUE, EN ESTOS CASOS, EL PACIENTE TIENE TODO EL DERECHO A EMPLEAR ACCIONES LEGALES SI CONSIDERA QUE EL DR. JACOBSEN HA SIDO NEGLIGENTE DE ALGUNA MANERA. RESPETAMOS EL DERECHO DE TODOS LOS PACIENTES A ACTUAR DE MANERA LEGAL. SI BIEN ALGUNAS RECLAMACIONES LEGALES EN MATERIA DE ATENCIÓN MÉDICA ESTÁN JUSTIFICADAS, TAMBIÉN SE PRESENTAN RECLAMACIONES LEGALES INJUSTAS EN NUESTRO PAÍS. Estas reclamaciones están incrementando las tasas de seguro y los costos de la atención médica. Estas acciones frívolas están afectando las decisiones judiciales para los pacientes que realmente merecen una indemnización. Estas acciones frívolas están impidiendo el acceso a la atención médica para algunos pacientes en algunos estados. Creemos que un acuerdo en las primeras etapas del tratamiento sobre el uso de expertos certificados por la junta ayudará a agilizar la resolución de las inquietudes. NOS COMPROMETEMOS A EMPLEAR ÚNICAMENTE A TESTIGOS MÉDICOS EXPERTOS CERTIFICADOS POR LA JUNTA AMERICANA DE ESPECIALISTAS MÉDICOS (ABMS), QUE SON CIRUJANOS PLÁSTICOS Y EJERCITAN ACTIVAMENTE EN EL ESTADO DE ARIZONA, EN CUALQUIER SITUACIÓN LEGAL, Y QUE CUMPLEN EL CÓDIGO DE ÉTICA DE NUESTRAS SOCIEDADES NACIONALES DE ESPECIALIDADES, LA SOCIEDAD AMERICANA DE CIRUJANOS PLÁSTICOS Y LA SOCIEDAD AMERICANA DE CIRUGÍA PLÁSTICA ESTÉTICA.

SI NO ESTÁ SATISFECHO CON SU ATENCIÓN MÉDICA Y DECIDE EMPLEAR LEGALMENTE, LE SOLICITAMOS QUE EMPLEE ÚNICAMENTE A TESTIGOS MÉDICOS EXPERTOS EN CIRUGÍA PLÁSTICA, CERTIFICADOS POR LA ABMS, QUE SON CIRUJANOS PLÁSTICOS Y EJERCITAN ACTIVAMENTE EN EL ESTADO DE ARIZONA.

CREEMOS QUE NO TENDRÁ QUE VOLVER A CONSIDERAR ESTO. PERO SI LO HACE, CUMPLIREMOS ESTE COMPROMISO CON USTED, YA QUE ES LO MEJOR PARA AMBOS.

ADEMÁS, EN CASO DE QUE SE INICIE O SE PROCESE UN CASO DE NEGLIGENCIA MÉDICA CON MÉRITO, ACEPTO UTILIZAR TESTIGOS MÉDICOS EXPERTOS CERTIFICADOS POR LA ABMS, QUE SEAN CIRUJANOS PLÁSTICOS Y EJERCITEN ACTIVAMENTE EN EL ESTADO DE ARIZONA. ADEMÁS, ACEPTO QUE ESTOS TESTIGOS EXPERTOS SE ADHERIRÁN A LAS DIRECTRICES Y/O AL CÓDIGO DE CONDUCTA DEFINIDOS POR LAS SOCIEDADES DE ESPECIALIDADES, LA SOCIEDAD AMERICANA DE CIRUJANOS PLÁSTICOS Y LA SOCIEDAD AMERICANA DE CIRUGÍA PLÁSTICA ESTÉTICA PARA TESTIGOS EXPERTOS. EN CONSIDERACIÓN ADICIONAL, YO, EL DR. WILLIAM M. JACOBSEN, ACEPTO LO MISMO.

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SECCIÓN 5: AUTORIZACIÓN PARA LA DIVULGACIÓN DE REGISTROS MÉDICOS

AUTORIZO A TODOS LOS PROVEEDORES DE ATENCIÓN MÉDICA Y HOSPITALES/INSTITUCIONES A DIVULGAR MI REGISTRO MÉDICO A:

FAX: 602.279.1701

WILLIAM M. JACOBSEN, M.D.
CIRUGÍA COSMÉTICA Y RESTAURADORA
2525 EAST ARIZONA BILTMORE CIRCLE, SUITE C236
PHOENIX, AZ 85016
TELÉFONO: 602-212-0100

REGISTROS MÉDICOS COMPLETOS, INCLUYENDO TODA LA INFORMACIÓN DE LA LISTA A CONTINUACIÓN:

TODOS LOS REGISTROS DEL HOSPITAL Y/O INSTITUCIÓN
REGISTROS DEL HOSPITAL/INSTITUCIÓN TRANSCRITOS (INCLUYENDO NOTAS DE LA OPERACIÓN, HISTORIAL/EXÁMENES FÍSICOS, CONSULTAS Y RESÚMENES DE ALTA
INFORMES DE LABORATORIO
INFORMES DE PATOLOGÍA
INFORMES DE DIAGNÓSTICO POR IMAGEN
INFORMES DE ECG/CARDÍACO
INFORMES DE FISIOTERAPIA/TERAPIA OCUPACIONAL
REGISTROS CLÍNICOS/DE CONSULTORIO MÉDICO
INFORMACIÓN DEL IMPLANTE (INCLUYENDO EL INFORME OPERATORIO) FOTOGRAFÍAS
REGISTROS DE VIH/SIDA/HEPATITIS
ESTE DOCUMENTO DEBE ESTAR FIRMADO POR EL PACIENTE O UNA PERSONA AUTORIZADA POR LA LEY.

AL FIRMAR A CONTINUACIÓN, AUTORIZO LA DIVULGACIÓN DE LOS REGISTROS ANTERIORES, SI EXISTEN:

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SECCIÓN 6: PRIVACIDAD DEL PACIENTE Y PRÁCTICAS DE COMUNICACIÓN

Queremos que nuestra comunicación con usted sea rápida y sencilla, pero para su seguridad, el Dr. Jacobsen cuenta con importantes prácticas de privacidad y comunicación para protegerlo.

¡Nuestro servidor de correo electrónico y nuestro sitio web cumplen con la ley HIPAA! ¡Protegemos sus datos!

Usted ha solicitado que el Dr. Jacobsen y su personal se comuniquen con usted por correo electrónico y buzón de voz. Si bien utilizaremos todos los medios razonables para proteger la seguridad y la confidencialidad de los correos electrónicos y los mensajes de voz enviados y recibidos, no podemos garantizar la seguridad y la confidencialidad de todas las comunicaciones por correo electrónico y buzón de voz.

AL FIRMAR A CONTINUACIÓN, RECONOZCO QUE HE LEÍDO Y ACEPTO LAS SIGUIENTES PRÁCTICAS DE PRIVACIDAD DEL PACIENTE Y COMUNICACIÓN POR CORREO ELECTRÓNICO Y SOY CONSCIENTE DE LOS RIESGOS DE USAR EL CORREO ELECTRÓNICO Y EL BUZÓN DE VOZ Y ACEPTO COMUNICARME CON EL DR. JACOBSEN Y SU OFICINA DE ESTA MANERA.

DR JACOBSEN WANTS YOU TO BE AWARE OF THE RISKS OF USING E-MAIL

TRANSMITTING YOUR PRIVATE PATIENT INFORMATION BY UNENCRYPTED E-MAIL, VOICE MAIL & TEXT MESSAGING HAS A NUMBER OF RISKS THAT YOU SHOULD CONSIDER. THESE RISKS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:

• EMAIL, VOICE MAIL & TEXT MESSAGING CAN BE CIRCULATED, FORWARDED AND STORED IN NUMEROUS PAPER AND ELECTRONIC FILES.
• E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE IMMEDIATELY BROADCAST WORLDWIDE AND RECEIVED BY MANY INTENDED AND UNINTENDED RECIPIENTS.
• E-MAIL, VOICE MAIL & TEXT MESSAGING SENDERS CAN EASILY MISADDRESS AN E-MAIL.
• E-MAIL, VOICE MAIL & TEXT MESSAGING IS EASIER TO FALSIFY THAN HANDWRITTEN OR SIGNED DOCUMENTS.
• BACKUP COPIES OF E-MAIL, VOICE MAIL & TEXT MESSAGING MAY EXIST EVEN AFTER THE SENDER OR THE RECIPIENT HAS DELETED HIS OR HER COPY.
• MANY EMPLOYERS AND ONLINE SERVICE PROVIDERS HAVE A RIGHT TO ARCHIVE AND INSPECT E-MAILS, VOICE MAIL & TEXT MESSAGING TRANSMITTED THROUGH THEIR SYSTEMS.
• E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE INTERCEPTED, ALTERED, FORWARDED OR USED WITHOUT AUTHORIZATION OR DETECTION.
• E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE USED TO INTRODUCE VIRUSES INTO COMPUTER SYSTEMS. 
• E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE USED AS EVIDENCE IN COURT.
• E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE LOST IN TRANSMISSION.
• E-MAILS, VOICE MAIL & TEXT MESSAGING CAN BE POSTED ON THE INTERNET OR OTHER PUBLICLY AVAILABLE NETWORKS.

E-MAIL COMMUNICATIONS

• IF OTHERS ARE INVOLVED IN YOUR HEALTHCARE, SUCH AS GUARDIANS OR HEALTH CARE AGENTS, YOUR AUTHORIZATION FOR E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS EXTENDS TO THEM, UNLESS YOU TELL US OTHERWISE IN WRITING.
• YOU UNDERSTAND AND AGREE THAT WE CANNOT GUARANTEE THE SECURITY, PRIVACY OR CONFIDENTIALITY OF E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS AND WE WILL NOT BE LIABLE FOR ANY IMPROPER DISCLOSURE OF CONFIDENTIAL INFORMATION, INCLUDING YOUR PATIENT INFORMATION, WHICH IS NOT CAUSED BY OUR INTENTIONAL MISCONDUCT.
• YOU UNDERSTAND AND AGREE THAT ALL E-MAILS, VOICE MAIL & TEXT MESSAGING BETWEEN US MAY BE PRINTED OR DOWNLOADED AND PLACED IN YOUR MEDICAL RECORD AND ANY PERSON AUTHORIZED TO ACCESS YOUR MEDICAL RECORD WILL HAVE ACCESS TO SUCH E-MAILS. YOU ALSO UNDERSTAND AND AGREE THAT WE MAY FORWARD YOUR E-MAILS TO STAFF AND AGENTS AND HEALTH CARE PROVIDERS AS NECESSARY FOR DIAGNOSIS, TREATMENT, REIMBURSEMENT AND OTHER TREATMENT, PAYMENT OR OPERATIONAL PURPOSES.
• E-MAIL, VOICE MAIL & TEXT MESSAGING IS PROVIDED AS A CONVENIENCE, NOT AS A SUBSTITUTE FOR PERSONAL TREATMENT OR OTHER MEDICAL CARE. ALTHOUGH WE WILL ENDEAVOR TO READ AND RESPOND PROMPTLY TO AN E-MAIL, VOICE MAIL & TEXT MESSAGING FROM YOU, WE CANNOT GUARANTEE THAT E-MAILS WILL BE READ AND RESPONDED TO WITHIN ANY PARTICULAR PERIOD OF TIME. IF YOUR E-MAIL, VOICE MAIL & TEXT MESSAGING REQUIRES OR INVITES A RESPONSE FROM US AND YOU HAVE NOT RECEIVED A RESPONSE WITHIN A REASONABLE TIME PERIOD (PLEASE ALLOW FOR AT LEAST 72 HOURS), IT IS YOUR RESPONSIBILITY TO FOLLOW UP TO DETERMINE WHETHER THE INTENDED RECIPIENT RECEIVED THE E-MAIL, VOICE MAIL & TEXT MESSAGING AND WHEN THE RECIPIENT WILL RESPOND. SIMILARLY, IT IS YOUR RESPONSIBILITY TO FOLLOW UP AND/OR SCHEDULE AN APPOINTMENT, IF WARRANTED.
• YOU MAY WITHDRAW YOUR REQUEST ONLY BY WRITTEN NOTICE TO US.
• YOU ARE RESPONSIBLE FOR PROTECTING YOUR PASSWORD OR OTHER MEANS OF ACCESS TO E-MAIL, VOICE MAIL & TEXT MESSAGING. YOU ARE ALSO RESPONSIBLE FOR KNOWING WHO CAN ACCESS YOUR E-MAIL, VOICE MAIL & TEXT MESSAGING ACCOUNT, SUCH AS A SPOUSE OR A FRIEND, AND SHOULD CHOOSE YOUR E-MAIL ACCOUNT ACCORDINGLY. YOU AGREE THAT WE ARE NOT LIABLE FOR BREACHES OF CONFIDENTIALITY CAUSED BY YOU OR ANY THIRD PARTY.
• YOU AGREE TO WAIVE AND RELEASE US AND OUR DIRECTORS, OFFICERS, MEMBERS, MANAGERS, EMPLOYEES, AGENTS, AND REPRESENTATIVES FROM AND AGAINST ANY AND ALL CLAIMS, LIABILITY, DAMAGES, COSTS AND FEES RELATING TO US E-MAILING YOU YOUR INFORMATION, INCLUDING UNAUTHORIZED ACCESS OR OTHER ISSUES THAT MAY ARISE. IN ADDITION, YOU AGREE TO BE BOUND TO THESE GUIDELINES, AS WELL AS ANY OTHER REQUIREMENTS OR GUIDELINES WE MAY PUBLISH RELATING TO E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS.
• YOU AGREE TO LIMIT OR AVOID USING YOUR EMPLOYER’S COMPUTER OR OTHER COMPUTERS THAT ARE NOT UNDER YOUR CONTROL, SUCH AS THOSE PROVIDED AT INTERNET CAFÉS OR LIBRARIES.
• YOU AGREE TO PROMPTLY INFORM US IN WRITING OF CHANGES IN YOUR E-MAIL ADDRESS, VOICE MAIL NUMBER & TEXT MESSAGING NUMBER. WE ARE NOT RESPONSIBLE FOR E-MAILS TO A PRIOR ADDRESS IF WE HAVE NOT BEEN ADVISED OF THE CHANGE IN WRITING.
• YOU AGREE TO PUT YOUR NAME IN THE BODY OF AN E-MAIL, VOICE MAIL & TEXT MESSAGING TO US SO WE KNOW WHO IS SENDING IT.
• YOU AGREE TO INCLUDE THE CATEGORY OF THE COMMUNICATION IN THE E- SUBJECT LINE OF AN EMAIL TO US FOR ROUTING PURPOSES (SUCH AS “BILLING QUESTION”, “PRESCRIPTION INFORMATION”, “MEDICAL ADVICE”).
• YOU AGREE TO REVIEW AN E-MAIL, VOICE MAIL & TEXT MESSAGING TO US TO MAKE SURE IT IS CLEAR AND THAT ALL RELEVANT INFORMATION IS PROVIDED BEFORE SENDING IT.
• YOU AGREE TO MAKE SURE THAT OUR E-MAIL, VOICE MAIL & TEXT MESSAGING ADDRESS IS CORRECT BEFORE SENDING AN E-MAIL TO US.
• YOU AGREE TO SEND US A REPLY MESSAGE OR DELIVERY RECEIPT WHEN WE SEND YOU AN E-MAIL, VOICE MAIL & TEXT MESSAGING SO WE KNOW YOU HAVE RECEIVED IT.
• YOU AGREE TO TAKE PRECAUTIONS TO PRESERVE THE CONFIDENTIALITY OF OUT E-MAILS, VOICE MAIL & TEXT MESSAGING, SUCH AS USING SCREEN SAVERS AND SAFEGUARDING YOUR COMPUTER PASSWORD.
• YOU AGREE TO ABIDE BY ALL OF THE ABOVE DURING YOUR EMAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS WITH US.

RECOMMENDATIONS

• IN ORDER TO HELP PROTECT YOUR COMPUTER AGAINST MALICIOUS SOFTWARE AND SAFEGUARD YOUR INFORMATION, SOFTWARE AND SYSTEM COMMUNICATIONS WE RECOMMEND YOU INSTALL AND REGULARLY UPDATE PROTECTIVE SOFTWARE, SUCH AS FIREWALL, ANTI-VIRUS AND ANTI-SPYWARE PROGRAMS.
• IN ORDER TO HELP REDUCE THE THREAT OF PEOPLE INAPPROPRIATELY INTERCEPTING AND READING YOUR E-MAILS, VOICE MAIL & TEXT MESSAGING, WE RECOMMEND YOU USE SOFTWARE TO ENCRYPT YOUR E-MAILS THAT CONTAIN INFORMATION YOU DETERMINE TO BE CONFIDENTIAL

PATIENT PRIVACY
 

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.

 

WILLIAM M. JACOBSEN, MD, P.C. IS DEDICATED TO MAINTAINING THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION. EACH TIME A PATIENT VISITS THIS OFFICE, A RECORD IS MADE THAT DESCRIBES THE TREATMENTS AND SERVICES PROVIDED. FEDERAL LAW OUTLINES SPECIFIC PRIVACY PROTECTIONS AND INDIVIDUAL RIGHTS RELATED TO THE INFORMATION WE MAINTAIN THAT IDENTIFIES YOU AS A PATIENT. PROTECTED INFORMATION INCLUDES DEMOGRAPHIC DATA AND FACTS ABOUT YOUR PAST, PRESENT, OR FUTURE PHYSICAL OR MENTAL HEALTH. OUR OFFICE HAS PUT IN PLACE POLICIES AND PROCEDURES TO HELP PROTECT YOUR HEALTH INFORMATION. WE ARE REQUIRED TO PROVIDE THIS NOTICE OUTLINING OUR LEGAL DUTIES AND RESPONSIBILITIES RELATED TO THE USE AND DISCLOSURE OF PATIENT IDENTIFIABLE HEALTH INFORMATION, PRIVACY PRACTICES, AND EXAMPLES OF HOW YOUR INFORMATION MAY BE USED OR DISCLOSED.

 

OUR PRACTICE WILL ABIDE BY THE TERMS OF THIS NOTICE. WE MAY REVISE THIS NOTICE AT ANY TIME. THE NEW NOTICE WILL BE POSTED IN OUR OFFICE IN A PROMINENT LOCATION. YOU CAN REQUEST A COPY OF OUR MOST CURRENT NOTICE AT ANY TIME. REVISIONS TO THE NOTICE WILL BE EFFECTIVE FOR ALL HEALTH CARE INFORMATION THIS OFFICE MAINTAINS: PAST, PRESENT, OR FUTURE.

 

PRACTICE MAY USE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION FOR THE FOLLOWING PURPOSES WITHOUT YOUR AUTHORIZATION:

1.       TREATMENT: WE MAY USE AND DISCLOSE YOUR IDENTIFIABLE HEALTH INFORMATION TO TREAT YOU AND ASSIST OTHERS IN YOUR TREATMENT. FOR INSTANCE, WE MAY SEND A COPY OF YOUR RECORDS TO ANOTHER DOCTOR SO THAT YOU CAN BE EVALUATED FOR A SPECIFIC CONDITION, OR WE MAY DISCLOSE INFORMATION TO OTHERS WHO TAKE PART IN YOUR CARE, SUCH AS YOUR SPOUSE, CHILDREN, OR PARENTS.

2.       PAYMENT: WE MAY USE YOUR HEALTH INFORMATION TO BILL AND COLLECT PAYMENT FOR SERVICES PROVIDED. THIS MAY INCLUDE PROVIDING YOUR INSURANCE COMPANY WITH THE DETAILS OF YOUR TREATMENT, SHARING YOUR PAYMENT INFORMATION WITH OTHER TREATMENT PROVIDERS, CONTACTING YOU OVER THE PHONE OR THROUGH THE MAIL ABOUT BALANCES, OR SENDING UNPAID BALANCES TO A COLLECTION AGENCY.

3.       HEALTH CARE OPERATIONS: WE MAY USE AND DISCLOSE HEALTH INFORMATION TO OPERATE OUR BUSINESS. FOR EXAMPLE, YOUR HEALTH INFORMATION MAY BE USED TO EVALUATE THE QUALITY OF CARE WE PROVIDE, FOR STATE LICENSING, OR TO IDENTIFY YOU BY NAME WHEN YOU VISIT THE OFFICE.

4.       APPOINTMENT REMINDERS: WE MAY USE AND DISCLOSE YOUR INFORMATION TO REMIND YOU OF APPOINTMENTS. WE MAY ALSO MAIL YOU A REMINDER FOR FOLLOW-UP VISITS.

5.       TREATMENT OPTIONS: WE MAY USE YOUR HEALTH INFORMATION TO INFORM YOU OF TREATMENT OPTIONS OR OTHER HEALTH-RELATED SERVICES WE OFFER THAT MAY BE OF INTEREST TO YOU.

6.       BUSINESS ASSOCIATES: WE MAY SHARE YOUR HEALTH INFORMATION WITH OTHER INDIVIDUALS OR COMPANIES THAT PERFORM VARIOUS ACTIVITIES FOR, OR ON BEHALF OF, OUR OFFICE SUCH AS AFTER-HOURS TELEPHONE ANSWERING, BILLING, OR QUALITY ASSURANCE. OUR BUSINESS ASSOCIATES AGREE TO PROTECT THE PRIVACY OF YOUR INFORMATION.

 

PRACTICE MAY DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION WHEN PERMITTED OR REQUIRED TO BY LAW, INCLUDING:

§   FOR PUBLIC HEALTH ACTIVITIES INCLUDING REPORTING OF CERTAIN COMMUNICABLE DISEASES.

§   FOR WORKERS’ COMPENSATION OR SIMILAR PROGRAMS AS REQUIRED BY LAW.

§   FOR PRODUCT RECALLS

§   TO REPORT ADVERSE REACTIONS TO MEDICATIONS

§   TO AUTHORITIES WHEN WE SUSPECT ABUSE, NEGLECT, OR DOMESTIC VIOLENCE.

§   TO HEALTH OVERSIGHT AGENCIES.

§   FOR CERTAIN JUDICIAL AND ADMINISTRATIVE PROCEEDINGS PURSUANT TO AN ADMINISTRATIVE ORDER.

§   FOR LAW ENFORCEMENT PURPOSES.

§   TO A MEDICAL EXAMINER, CORONER, OR FUNERAL DIRECTOR.

§   FOR THE FACILITATION OF ORGAN, EYE, OR TISSUE DONATION IF YOU ARE AN ORGAN DONOR.

§   FOR RESEARCH PURPOSES UNDER STRICTLY LIMITED CIRCUMSTANCES.

§   TO AVERT A SERIOUS THREAT TO YOUR HEALTH AND SAFETY OR THAT OF OTHERS.

§   FOR GOVERNMENTAL PURPOSES, SUCH AS MILITARY SERVICE OR FOR NATIONAL SECURITY.

§   IN THE EVENT OF AN EMERGENCY OR FOR DISASTER RELIEF.

§   FOR A HOSPITAL DIRECTORY

§   TO PROVIDE MENTAL HEALTH CARE SERVICES WITH YOUR PRIOR WRITTEN PERMISSION.

§   TO MARKET OUR SERVICES AND SELL YOUR INFORMATION WITH YOUR PRIOR WRITTEN PERMISSION.

§   TO RAISE FUNDS, BUT AFTER THE FIRST CONTACT YOU CAN REQUEST THAT WE NOT CONTACT YOU AGAIN.

§   IN ANY OTHER INSTANCE REQUIRED BY LAW.

§   IN BILLING DISPUTE WITH CREDIT CARD COMPANIES, MERCHANTS OR BANK TO DISCREETLY COORBORATE SERVICES RECEIVED BY YOU

 

 

IF YOU ARE NOT ABLE TO TELL US YOUR PREFERENCE, FOR EXAMPLE, IF YOU ARE UNCONSCIOUS, PRACTICE MAY GO AHEAD AND SHARE YOUR INFORMATION IF WE BELIEVE IT IS IN YOUR BEST INTEREST. PRACTICE MAY ALSO DISCLOSE YOUR INFORMATION TO FAMILY MEMBERS AND/OR OTHER PERSONS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. PRACTICE MAY LEAVE MESSAGES FOR YOU AT HOME OR WORK ABOUT YOUR VISITS OR TEST RESULTS. IF YOU DO NOT WANT US TO DO SO, PLEASE INFORM OUR OFFICE IN WRITING.

 

ALL OTHER USES AND DISCLOSURES OF YOUR INFORMATION TO OTHERS WILL REQUIRE A WRITTEN, SIGNED AUTHORIZATION FROM YOU. YOU HAVE THE RIGHT TO REVOKE YOUR AUTHORIZATION AT ANY TIME EXCEPT TO THE EXTENT THAT WE HAVE ALREADY ACTED ON IT. SHOULD YOU REQUIRE YOUR RECORDS TO BE RELEASED, PRACTICE WILL PROVIDE YOU WITH AN AUTHORIZATION FORM TO COMPLETE AND RETURN TO THE ADDRESS LISTED ON IT.

 

YOUR HEALTH RECORD IS THE PHYSICAL PROPERTY OF PRACTICE. THE INFORMATION CONTAINED IN IT BELONGS TO YOU. BELOW IS A LIST OF YOUR RIGHTS REGARDING INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. ALL REQUESTS RELATED TO THESE ITEMS MUST BE MADE IN WRITING TO OUR PRIVACY OFFICER AT THE ADDRESS LISTED BELOW. WE WILL PROVIDE YOU WITH APPROPRIATE FORMS TO EXERCISE THESE RIGHTS. WE WILL NOTIFY YOU, IN WRITING, IF YOUR REQUESTS CANNOT BE GRANTED.

 

1.       RESTRICTIONS ON USE AND DISCLOSURE: YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS ON HOW WE USE AND DISCLOSE YOUR HEALTH INFORMATION. THIS INCLUDES REQUESTS TO RESTRICT DISCLOSURE OF YOUR HEALTH INFORMATION TO ONLY CERTAIN INDIVIDUALS, OR ENTITIES, INVOLVED IN YOUR CARE SUCH AS FAMILY MEMBERS AND INSURANCE COMPANIES. WE ARE NOT REQUIRED TO AGREE WITH YOUR REQUEST. IF WE AGREE, WE ARE BOUND TO THE AGREEMENT UNLESS DISCLOSURE IS OTHERWISE REQUIRED OR AUTHORIZED BY LAW. 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.

2.       CONFIDENTIAL COMMUNICATIONS: YOU HAVE THE RIGHT TO REQUEST THAT WE COMMUNICATE WITH YOU OR SOMEONE YOU CHOOSE TO ACT FOR YOU IN A PARTICULAR MANNER OR AT A CERTAIN LOCATION. FOR EXAMPLE, YOU MAY REQUEST THAT WE ONLY CONTACT YOU AT HOME. WE WILL ACCOMMODATE REASONABLE REQUESTS. 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.

3.       ACCESS: YOU HAVE THE RIGHT TO INSPECT OR REQUEST A COPY OF RECORDS USED TO MAKE DECISIONS ABOUT YOUR HEALTH CARE, INCLUDING YOUR MEDICAL CHART AND BILLING RECORDS. THIS OFFICE WILL SCHEDULE APPOINTMENTS FOR RECORD INSPECTION. WE MAY CHARGE A FEE FOR PROVIDING YOU COPIES OF YOUR RECORDS. UNDER SPECIAL CIRCUMSTANCES, WE MAY DENY YOUR REQUEST TO INSPECT AND/OR COPY YOUR RECORDS. YOU MAY REQUEST A REVIEW OF THIS DENIAL. YOU MAY ALSO REQUEST AN ELECTRONIC COPY OF YOUR RECORDS BE PROVIDED. THIS ELECTRONIC COPY MAY BE SENT USING E-MAIL TO YOUR SPECIFIED ADDRESS, CD FOR FLASH DRIVE. PLEASE NOTE THAT E-MAIL COMMUNICATIONS ARE NOT A SECURE METHOD FOR TRANSPORT.

4.       RECORD AMENDMENT: YOU HAVE THE RIGHT TO REQUEST AMENDMENTS TO YOUR HEALTH RECORDS CREATED BY AND FOR THIS PRACTICE IF YOU FEEL THEY ARE INCORRECT OR INCOMPLETE. WE MAY ACCEPT OR DENY YOUR REQUEST. IF WE DENY YOUR REQUEST, YOU HAVE THE RIGHT TO PROVIDE A STATEMENT OF DISAGREEMENT.

5.       ACCOUNTING OF DISCLOSURES: YOU HAVE THE RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES. THIS MEANS YOU MAY REQUEST A LIST OF CERTAIN DISCLOSURES PRACTICE HAS MADE OF YOUR RECORDS. UPON YOUR REQUEST, WE WILL PROVIDE THIS INFORMATION TO YOU ONE TIME FREE DURING EACH TWELVE (12) MONTH PERIOD. THERE MAY BE A FEE FOR ADDITIONAL COPIES.

6.       COPY OF NOTICE: YOU HAVE THE RIGHT TO REQUEST THAT WE PROVIDE YOU WITH A PAPER COPY OF THIS NOTICE OF PRIVACY PRACTICES.

WHEN FEDERAL AND STATE PRIVACY LAWS DIFFER, AND STATE LAW IS MORE PROTECTIVE OF YOUR INFORMATION OR PROVIDES YOU WITH GREATER ACCESS TO YOUR INFORMATION, STATE LAW MAY OVERRIDE FEDERAL LAW.

 

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRACTICE’S PRIVACY OFFICER AT (602) 212-0100. IF YOU FEEL YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU HAVE THE RIGHT TO FILE A WRITTEN COMPLAINT WITH OUR OFFICE. YOU MAY ALSO FILE A COMPLAINT WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS BY SENDING A LETTER TO 200 INDEPENDENCE AVENUE, S.W., WASHINGTON, D.C 20201 OR CALLING 1-877-696-6775, OR VISITING: WWW.HHS.GOV/OCR/PRIVACY/HIPAA/COMPLAINTS/ 

 

THERE WILL BE NO RETALIATION FOR FILING A COMPLAINT.

 

FOR MORE INFORMATION SEE: WWW.HHS.GOV/OCR/PRIVACY/HIPAA/UNDERSTANDING/CONSUMERS/NOTICEPP.HTML 

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SECCIÓN 7: IMPAGO DEL SEGURO

TENGA EN CUENTA QUE SU COMPAÑÍA DE SEGUROS PODRÍA NEGARLE LA COBERTURA DE SU CIRUGÍA. ESTO PUEDE SER NEGADO POR SERVICIOS NO CUBIERTOS, CIRUGÍAS ESTÉTICAS O INNECESARIAS, DEFINIDAS DE DIVERSAS MANERAS POR SU COMPAÑÍA DE SEGUROS. ESTO PUEDE OCURRIR INCLUSO SI SU CIRUGÍA FUE APROBADA O AUTORIZADA CON ANTELACIÓN, E INCLUSO SI USTED LA CONSIDERÓ NECESARIA Y EL DR. JACOBSEN CONSIDERÓ QUE LO ERA. HACEMOS TODO LO POSIBLE PARA APELAR EN SU NOMBRE DURANTE 60 DÍAS. SIN EMBARGO, USTED ES RESPONSABLE DE LOS GASTOS DE LA CIRUGÍA SI SU COMPAÑÍA DE SEGUROS NO LE CUBRE POR CUALQUIER MOTIVO. Si desea continuar apelando ante su compañía de seguros, puede hacerlo. Si tiene cobertura, le reembolsaremos su pago. DESPUÉS DE 60 DÍAS, CUANDO LLAME PARA OBTENER UNA EXPLICACIÓN, SU ASEGURADORA LE INFORMARÁ QUE EL DR. JACOBSEN SOLO NECESITA "X" PARA QUE SU RECLAMACIÓN SEA APROBADA. TENGA LA SEGURIDAD DE QUE HEMOS REALIZADO TODOS LOS PASOS POSIBLES PARA QUE SU RECLAMACIÓN SEA APROBADA. EL REPRESENTANTE IMPLICARÁ QUE EL PERSONAL DE FACTURACIÓN DEL DR. JACOBSEN FALLÓ EN ALGUNO PASO DEL PROCESO, PERO HEMOS HECHO TODO LO POSIBLE A SU FAVOR. EL PERSONAL DE FACTURACIÓN TIENE EXPERIENCIA Y VE SU MEJOR INTERÉS.

DESPUÉS DE 60 DÍAS, USTED ACEPTA PAGAR SU FACTURA A PESAR DE CUALQUIER PROBLEMA CONTINUO QUE TENGA CON SU ASEGURADORA.

FIRME A CONTINUACIÓN QUE ENTIENDE ESTA RESPONSABILIDAD. GRACIAS, DR. JACOBSEN Y PERSONAL.

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SECCIÓN 8: POLÍTICA DE PRIVACIDAD EN CASO DE NO PAGO

TENGA EN CUENTA QUE, SI RECIBE SERVICIOS Y EXISTE UNA DISPUTA DE PAGO CON UNA FUENTE, COMO UNA TARJETA DE CRÉDITO O UNA ENTIDAD BANCARIA, EL DR. JACOBSEN UTILIZARÁ DISCRETAMENTE SU INFORMACIÓN MÉDICA PRIVADA PARA CORROBORAR EL SERVICIO RECIBIDO, SI LA FUENTE DE PAGO ASÍ LO REQUIERE. EL DR. JACOBSEN LE RECOMIENDA MANTENER LA PRIVACIDAD DE SUS FUENTES DE PAGO PARA QUE SU INFORMACIÓN MÉDICA TAMBIÉN PERMANEZCA COMPLETAMENTE PRIVADA. EL EFECTIVO, LOS CHEQUES DE CAJA Y LOS CHEQUES PERSONALES SON LAS FUENTES DE PAGO MÁS PRIVADAS PARA USTED. EL NO PAGO DE LOS SERVICIOS FACTURADOS DURANTE MÁS DE 60 DÍAS INCURRE EN UN CARGO ADMINISTRATIVO DE $75 Y EL 5% DEL SALDO POR CADA MES O PARTE DEL MES NO PAGADO.

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HAGA CLIC EN "SIGUIENTE" EN ESTE FORMULARIO DESPUÉS DE LEER A CONTINUACIÓN.

Al ENVIAR este formulario, acepto todas las condiciones y certifico que lo he leído y comprendido en su totalidad. También entiendo que tengo la opción de completarlo personalmente en la consulta del Dr. J. Una vez que lo firme y lo envíe, se le enviará una copia por correo electrónico. Si este formulario de envío en línea está INCOMPLETO, podrá completarlo en la consulta a su llegada. Tenga en cuenta que algunos campos obligatorios están marcados en rojo. Estos son datos esenciales para que el Dr. Jacobsen lo registre en su historial médico electrónico.

DESPUÉS DE HACER CLIC EN "SIGUIENTE", APARECERÁ EL BOTÓN "ENVIAR". HAGA CLIC EN EL BOTÓN "ENVIAR" Y YA HABRÍA TERMINADO. RECIBIRÁ UNA COPIA POR CORREO ELECTRÓNICO EN BREVE.

¡GRACIAS! PERSONAL DEL DR. J