HIPAA

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

I have reviewed Health by Design's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

In order to evaluate the ability of my heart to respond to exercise, I voluntarily agree to undergo an exercise stress test under the supervision of the Health by Design physicians.

The test that I will undergo will be performed with the amount of effort increasing every three minutes or at the preference of the physician. This increase in effort will continue until symptoms such as fatigue, shortness of breath, or chest discomfort may appear. During the test and afterward (during the recovery period), the supervising physician and nurse will keep my pulse, blood pressure, and electrocardiogram under surveillance.

There exists the possibility of certain changes occurring during the test. They include abnormal blood pressure, fainting, disorders of the heartbeat (too rapid, too slow, or ineffective), and the potential risk for an acute myocardial infarction (heart attack). Every effort will be made to minimize them through preliminary examination and observations during testing. Emergency equipment and trained personnel are available to deal with unusual situations should they arise. The information which is obtained will be created as privileged and confidential.

I have read the above and give my consent to proceed with the test. I will not hold the personnel involved or Health by Design responsible if untoward events or injuries result.

I understand that if I am pregnant and have x-rays taken, which expose my lower torso to radiation, it is possible to injure the fetus, and I should not undergo the scan.

FEMALES: Please answer the following. 

 

I am advising my doctor that:

The DEXA-Scan will not be performed if you have answered "yes" to any of the above questions or if there is a possibility of pregnancy. A voucher is available if you would like to have this procedure done within a year of your physical exam.

With full understanding of the above and believing that I am not currently at risk, I wish to have the DEXA-Scan study performed.

As part of your comprehensive examination, you will receive an ultrasound measurement of your carotid artery intima-media thickness (CIMT) During this examination, certain abnormalities may be noted on your thyroid or in your carotid arteries that your physician may wish to further evaluate with additional ultrasound studies performed by the sonographer. Also, you may be due for one time abdominal aortic aneurysm screening due to age (over 65) or certain risk factors (such as family history Additional ultrasound studies performed to better evaluate abnormalities or as indicated may include:

abdominal aortic aneurysm screen (if indicated)

Ultrasound does not involve radiation, and these studies do not involve radiation exposure. If you have questions about these ultrasound studies, please feel free to discuss them with your physician or your nurse.

With your signed permission, the necessary studies will be done, and if needed, the images will be electronically transmitted to a radiologist for interpretation and report. This report will be sent to your executive exam physician and discussed with you. Copies of the report can be sent to your personal

These additional examinations will not cost you or your company additional money, and no claim will be submitted to your insurance company.