Initial Visit Patient Forms (MDR)

Initial Visit Patient Forms (MDR)

Get more information about your patient medical history with this simple and easy to use form Form Preview
  • Certain Waivers under HIPAA.

    (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician.

    (b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following:

    1. E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
    2. Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.
  • Patient acknowledges and agrees that Physician and Group, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to MD Revolution staff.

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  • give my express permission to MD Revolution and Dr. Samir B Damani, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.

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