portlavacaclinic.com - New Patient Form (English)

Patient Information Sheet/ Patient Privacy & Rights

Port Lavaca Clinic Associates
Patient Demographics
Patient Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver's License#
SS#
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone#
Please enter a valid phone number.Format: (000) 000-0000.
Race
Ethnicity
Preferred Language
Email address
example@example.com
Person Responsible for Bill
Responsible Party's Full Name

First NameLast Name
Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient

Please list spouse and minor children under the age of 21 who you are responsible for

Rows	Spouse / Minor Child Name
1.
2.
3.
4.
5.
6.

Emergency Contact
Name
Phone#
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Insurance Information
Primary Insurance
Policy Holder
Relation to Policy Holder
Policy Holder DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy#
Group#
Gender
SS# of Insured
Employer
Second Insurance
Policy Holder
Relation to Policy Holder
Policy Holder DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy#
Group#
Gender
SS# of Insured
Employer
Third Insurance
Policy Holder
Relation to Policy Holder
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy#
Group#
SS# of Insured
Gender
PATIENT BILLING AND PRIVACY
BY SIGNING BELOW YOU ARE CERTIFYING THAT THE ABOVE INFORMATION IS ACCURATE, that you are consenting for medical care & giving Port Lavaca Clinic Associates, PA. Permission to bill your insurance carrier for all medical care provided here. Your signature on this paper will be the signature on file giving us permission to file your insurance claim with "Signature on File" for Medicare, Medicaid, and all other types of insurance. YOU ARE ALSO AGREEING THAT PAYMENT OF YOUR MEDICAL CARE IS ULTIMATELY YOUR RESPONSIBILITY. You are also authorizing the release of any medical or other information necessary to process your medical claims as well as to other referring providers. You have access to all of your personal medical records during normal business hours. Records will be provided no more than 15 business days from receipt of request. A fee for this may be required. If you find errors in your medical records you have the rights to request changes to correct any errors. You have the right to request disclosure of non-routine disclosures of your health information. Your signature also shows that you have received our two pages Notice of privacy practice form.
Patient Signature (Responsible Adult if Patient is under 18 yrs. old)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

NOTICE OF PRIVACY PRACTICES

Port Lavaca Clinic Associates
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.

OUR RESPONSIBILITIES

Port Lavaca Clinic Associates is required by law to:
- Maintain the privacy of your protected health information ("PHI")
- Provide you with this Notice of our legal duties and privacy practices
- Follow the terms of the Notice currently in effect
- Notify you if a breach occurs that may have compromised the privacy or security of your information
HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

1. Treatment
We may use and disclose your PHI to provide, coordinate, or manage your healthcare.
Example: Sharing information with a specialist, lab, or hospital.

2. Payment
We may use and disclose your PHI to bill and receive payment.
Example: Sending information to your insurance company for claims processing.

3. Healthcare Operations
We may use your PHI for clinic operations.
Examples include:
- Quality improvement
- Staff training
- Licensing and accreditation
4. Appointment Reminders and Health-Related Benefits
We may contact you for:
- Appointment reminders
- Follow-up care
- Treatment options or health-related services
5. Individuals Involved in Your Care
We may share information with family members, friends, or others involved in your care unless you object.

6. Required by Law
We will disclose your PHI when required by federal, state, or local law.

7. Public Health Activities
We may disclose your information for:
- Disease control and prevention
- Reporting births, deaths, or infections
- Reporting abuse or neglect
8. Health Oversight Activities
We may disclose PHI to health oversight agencies for audits, inspections, and investigations.

9. Law Enforcement
We may release PHI:
- In response to a court order or subpoena
- To report certain crimes
10. Serious Threat to Health or Safety
We may disclose information to prevent or lessen a serious threat.

11. Workers' Compensation
We may disclose PHI as authorized for workers' compensation claims.

12. Research
We may use or disclose PHI for research under strict approval processes.

USES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

We will not use or disclose your PHI without your written authorization for:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
You may revoke authorization at any time in writing.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. Right to Access
You may inspect and obtain a copy of your medical records.

2. Right to Amend
You may request corrections to your health information.

3. Right to an Accounting of Disclosures
You may request a list of certain disclosures we have made.

4. Right to Request Restrictions
You may request limits on how we use or disclose your PHI.
We are not required to agree, except in certain cases involving self-pay.

5. Right to Request Confidential Communications
You may request we contact you in a specific way (e.g., only by phone or mail).

6. Right to a Paper Copy
You may request a paper copy of this Notice at any time.

CHANGES TO THIS NOTICE

We reserve the right to change this Notice at any time. Updated versions will be available in our clinic and upon request.
COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with:

Port Lavaca Clinic Associates
Phone:Area Code Phone Number

Or with the U.S. Department of Health and Human Services:
Office for Civil Rights
You will not be penalized for filing a complaint.
CONTACT INFORMATION

If you have questions about this Notice, contact:

Port Lavaca Clinic Associates
Address
Phone:Area Code Phone Number

Telemedicine Visit Rules & Expectations
Appropriate Clothing
Patients must wear proper, non-revealing clothing during the entire visit.

Private Environment
The visit must take place in a quiet, private location where your personal health information cannot be overheard. Avoid public areas, shared spaces, or environments with distractions. Ensure good lighting so the provider can see you clearly.

Safety Requirements
Do not attend a telemedicine visit while driving or operating any type of vehicle or machinery. All vehicles or machinery must be completely stopped and safely parked before the appointment begins.

Technology Setup
Use a device with a functioning camera and microphone. Ensure your internet connection is stable before the appointment. Keep your device plugged in or fully charged.

Respect & Professionalism
Treat the visit as you would an in-person appointment. Avoid multitasking during the session. Follow your provider's instructions and be prepared with any requested documents, medication lists, or readings.

Rule Enforcement
Failure to follow these rules will result in the telemedicine session being terminated. The appointment must then be rescheduled.

Thank you for your cooperation.

Port Lavaca Clinic

Consent to Treatment of a Minor
Name of Minor
Minor's Treatment: I am the parent/guardian, Printed Name of Parent/Guardian

For the above named minor patient I authorize Port Lavaca Clinic’s medical staff to provide medical/dental/vision, and/or emergency treatment to my child. I understand that this authorization is given in advance of any specific diagnosis or treatment. I, the parent/guardian am financially responsible to pay the cost of the services rendered to the child in accordance with the regular rate and terms of Port Lavaca Clinic. Family members (grandparents, aunt/uncles, cousins, adult siblings) and the following designated unrelated adults:
Designated Unrelated Adults
May bring the minor in for treatment at the Port Lavaca Clinic.
I understand that this form will be valid and remain in effect for one year from the date signed below. This form has been fully explained to me and I understand its contents.
Signature Parent/Guardian
Relationship to Minor
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Authorization to Release Patient Information
Patient's Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security #
This is to authorize the following person(s)
Access to my personal information as shown below
This authorization will remain in effect until written notification from my self is received by the Port Lavaca Clinic.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

Rows	Yes	No	When
Hepatitis B
Tetanus Immunization
Flu Immunization
Pneumonia Immunization
Other

Rows	Which Family Member?	Approximate age when diagnosed
Cancer (describe type)
High Blood Pressure
Heart Disease
Diabetes
Stroke
Mental Illness (anxiety, depression, etc.)
Blood/clotting Disease

Patient Information Sheet/ Patient Privacy & Rights

Patient Demographics

Person Responsible for Bill

Emergency Contact

Insurance Information

Primary Insurance

Second Insurance

Third Insurance

PATIENT BILLING AND PRIVACY

NOTICE OF PRIVACY PRACTICES

OUR RESPONSIBILITIES

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION

USES THAT REQUIRE YOUR WRITTEN AUTHORIZATION

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

CHANGES TO THIS NOTICE

COMPLAINTS

Telemedicine Visit Rules & Expectations

HEALTH HISTORY

PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS:

FEMALE HEALTH HISTORY

Male Health History

When was your last?

PREVENTION

Port Lavaca Clinic

Authorization to Release Patient Information

PEDIATRIC HEALTH HISTORY

Pregnancy & Birth Section

Nutrition & Feeding Section

SLEEP

DEVELOPMENT

DENTAL HISTORY

IMMUNIZATIONS/INFECTIOUS DISEASES

EXPOSURES/HABITS

Family History

SCHOOL HISTORY

SOCIAL HISTORY

Rows	Allergy or Reaction
1.
2.
3.
4.

Rows	Allergy or Reaction
1.
2.
3.
4.