Patient Information

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale: 

I am being treated at Future Hope Total Health (FHTH) a division of Future Hope Health Group (FHHG) and I consent to all medical and surgical care, examinations, and tests determined by my provider that are necessary for me.  Though I expect the care given will meet customary standards, I understand there are no guarantees concerning the results of my care.  I also understand that if I do not follow my provider’s recommendations as they may relate to my health, the provider and this office will not be responsible for any injuries or damages that are the result of my non-compliance.  I understand that if an employee or individual associated with Future Hope Health Group is exposed to my blood or body fluids, I will be tested for hepatitis viruses and the HIV virus.  I also understand that I will receive education related to this testing and I will not be charged for testing and education related to the exposure.

Consent to Use of Information
Electronic Health Records— I understand that FHHG) utilizes electronic health records (EHR) and I consent to share my information with their EHR system.  I agree that (with consent when indicated) records may be shared electronically.  I consent to the inclusion of the EHR of sensitive diagnoses and related information such as HIV?AIDS status, sexually transmitted diseases, genetic information, and mental health and substance abuse, etc.  The EHR will be accessible by FHHG credentialed practitioners as well as other individuals approved to access them for purposes related to treatment, payment, health care operations, and /or other purposes permitted by federal and state laws.  FHHG has implemented administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPAA.
   Use and Disclosure of Information— I agree that FHHG may use and disclose my health information for a range of purposes including treatment, eligibility verification, state and federal government programs, Worker’s Compensation programs, pre-authorizations for procedures, quality of care assessment & improvement activities, evaluating the performance of employees, conducting medical training & educational programs, medical reviews/audits, compliance with legal, regulatory & accreditation requirements of public health & health oversight services when required.
   As per the Membership Agreement, I understand that information will not be disclosed to other providers/ hospitals/ health departments without written consent by the patient or their guardian.  

Acknowledgment of Receipt of “Notice of Privacy Practices”
I acknowledge that I have received or been offered a copy of FHHG’s “Notice of Privacy Practices” (HIPPAA) which provides information on how the office may use or disclose protected health information (PHI) for purposes of treatment, payment, or health care operations.

Financial Responsibility
   I acknowledge that I have read and understood the financial agreement as described in the FHPC Membership Agreement. 
   I understand that I am financially responsible for the payment of all charges incurred which are not covered by my Membership Agreement.  We will make every effort to explain those to you prior to services rendered.  Payment will be taken at the time of service.
   I understand that supplements, medications, or other suggested treatment modalities not explicitly outlined in the membership agreement are my financial responsibility.
   I understand that FHHG is not responsible for the fees charged by any outside vendor such as (but not limited to) a lab, hospital, imaging facility, or specialist.  
   I understand that FHPC does NOT have agreements with insurance companies and will not file claims on my behalf.   

Personal Valuables
I understand that FHHG does not accept responsibility for any lost, stolen, or damaged personal items while I am at the office.

Cancellation and No-Show Policy
In order to meet the needs of all our patients for timely appointments, our office requires a minimum of 72 hours to cancel/change an appointment.  Your appointment time is reserved for YOU.  If you don’t keep that time, we can’t meet your needs or those of our other members.  
If you arrive too late to both see you and finish an appointment in a timely manner, you may be asked to reschedule your appointment.  We don’t want our providers to try to rush through an appointment or to make our next member wait.
We reserve the right to charge a fee for a no-show or late cancellation/re-scheduling of an appointment.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. 

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, or text. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 I, the undersigned, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information and Consent Form and any subsequent changes in office policy.   I understand that this consent shall remain in force from this time forward.