Lamb Healthcare Center

The undersigned hereby makes the following acknowledgements and Agreements regarding treatment to be provided to the patient whose name appears below:

 

1. Consent to Treatment: I understand that medical treatment is necessary, and that a physician, physician assistant, nurse practitioner and/or other employees of the Clinic will perform such medical treatment and procedures.  The physician assistant and nurse practitioner are not physicians, but do function under the supervision of a physician either directly or via protocols established by a physician.  As a patient, you have the right to be seen only by a physician.  I hereby grant my authorization and consent for such treatment and procedures.
2. Agreement to Pay for Services: I acknowledge and accept that no guarantee has been given as to the results of these treatments.  I further acknowledge and accept that any treatment(s) given may not help me and may make my condition worse.  For, and in consideration of, the care and treatment provided to the patient, I promise to pay, or arrange for payment, AT THE TIME OF THIS VISIT, all charges due for services rendered to or on behalf of the patient.  Payment may be made by cash, check or credit card.  Legal action to collect money from insufficient fund checks or stop payment checks will be taken at the patient's expense.
3. Assignment and Instruction for Direct Payment to Doctor. I hereby instruct and direct my insurance company to pay directly to Lamb Healthcare Center 1500 S Sunset Ave, Littlefield, Texas, 79339.  If my current policy prohibits direct payment to medical practitioners, then I also instruct and direct my insurance company to make out the check to me and mail it directly to Lamb Healthcare Center, 1500 S Sunset Ave, Littlefield, Texas, 79339.  For the professional and medical benefits otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered, THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THE POLICY.  This payment will not exceed my indebtedness to the above named assignee(s).  Also, I have agreed to pay, in a current manner, the balance due of any and all professional and medical service charges over and above any insurance payment.  I understand that I am fully financially responsible for all these charges at all times.
4. Release of Medical Information. I authorize the release of any and all information pertinent to my case to any insurance company, adjuster, or attorney involved in this case who makes the request in writing.  Further, I authorize the release of my medical information to my personal or referral physician.
5. Risks. Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me.  I realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, blood clots in the veins and lungs, hemorrhage, allergic reactions, failure of treatment, and even death.  I give my consent for Lamb Sleep Center to provide such treatment as necessary.
    

I HAVE READ THE ABOVE Acknowledgements and Agreements, and fully understand and agree to them.

A copy of this form shall be considered as acceptable and as valid as the original.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

 

1. Uses and Disclosures of Protected Health Information

 

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

 

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. For 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. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. 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 necessary, to contact you to remind you of your appointment.

 

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; Workers’ Compensation; Inmates; Required Uses and Disclosures; Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

 

Other Permitted and Required uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

 

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

 

Your Rights

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 administration 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 physician is not required to agree to a restriction that you may request. If your physician believes that 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 use another Healthcare Professional.

 

You have the right to request to receive confidential communications from us by an alternative means or at an alternative location. 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 alternatively, i.e., electronically.

 

You may have the right to have your physician amend your protected health information. 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 have the 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.

 

Complaints

You may complain to us or to 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 privacy contact of your complaint. We will not retaliate against you for filing a complaint.

 

This notice was published and becomes effective on/or before April 14, 2003.

 

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 our HIPAA Compliance Office in person or by phone at our Main Phone Number.

 

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Do you ever wake up with:

Daytime Sleepiness

Medical Data

Other Sleep Symptoms

The Epworth Sleepiness Scale is widely used in the field of sleep medicine as a subjective measure of a patient’s sleepiness. The test is a list of eight situations in which you rate your tendency to become sleepy on a scale of 0, no chance of dozing to 3, high chance of dozing. When you finish the test, add up the value of your responses. Your total score is based on a scale if 0 to 24. The scale estimates whether you are experiencing excessive sleepiness that possibly requires medical attention.

How Sleepy Are You?

How likely are you to doze off or fall asleep in the following situations? You should rate your chances of dozing off, not just feeling tired. Even if you have not done some of these things recently try to determine how they would have affected you. For each situation, decide whether or not you would have:

No chance of dozing = 0 
Slight chance of dozing = 1
Moderate chance of dozing = 2
High chance of dozing = 3

Interpretation: 0-7 Unlikely that you are abnormally sleepy, 8-9 you have an average amount of daytime sleepiness, 10-15 you may be excessively sleepy depending on situation. You may want to consider medical attention; 16-24 you are excessively sleep and should seek medical attention.