Name: (First)______________________________ (Last) ______________________________ (MI)
Previous Doctor Name: _____________________ Phone Number:
Past medical history (check all that apply):
Last Pap smear: _____________ History of abnormal pap (explain):
Last mammogram: ___________ History of abnormal mammogram (explain):
Last colonoscopy: ___________ History of abnormal colonoscopy (explain):
History of varicella vaccine or chickenpox? (y/n) __________ When:
History of shingles or shingles vaccine? (y/n) __________ When: History of MMR vaccine? (y/n) __________ When: History of flu vaccines? (y/n) __________ When: Other:
Allergies: (Medications)____________________________ (Food)
Current smoker (_____ packs/day)□ Past smoker (quit _____ years ago) Infrequent□ Regularly (_____ times per week)
Family History (please list medical problems of each family member)
Mother: ________________________________ Father:
Paternal Grandfather:______________________Paternal Grandmother:
Maternal Grandfather:_____________________Maternal Grandmother:
Review of Systems (Check all that apply, please review list carefully)
Chest pain □ Irregular heartbeat □ Difficulty breathing when lying flat
As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company
to pay for the services we have provided to you. PLEASE NOTE: if your insurance changes it is the patient’s responsibility to verify
that VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE PLLC is contracted with the new insurance plan. Copays, deductibles, and
coinsurance are due at the time of service, NO EXCEPTIONS will be made.
We do NOT accept cash or checks, the only form of payment accepted is credit/debit cards as noted below.
Appointments/Cancellations: We gladly reserve appointment times for you and appreciate that you have chosen Vitality for your care. As a courtesy, we will remind you of your appointment by calling and/or text/emailing you prior to your scheduled date and time. However, in the event your mailbox is full, or your line is busy, our efforts to contact you may be unsuccessful. An appointment is a contract of time reserved for your treatment. We respect our patient’s valuable time, and we request the same courtesy from our patients. Please extend this courtesy should you need to cancel and/or reschedule your appointment. We reserve the right to charge $75 for regular appointments cancelled or broken without advance notice of 2 business days.
I authorize payment to be made directly to Vitality by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize the release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.
Vitality is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. We will store your card number in a secure, compliant location in your electronic medical record. For security reasons only the last four digits will be visible to our staff. Credit cards on file will be used to pay copays when you are seen in our office, including account balances, after your insurance processes your claim.
You will be notified by email of pending charges 5 days before the charges occur, and again when the credit card is charged. You will also receive an email receipt when the card is charged.
I have read and agree to the above policies.
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; THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
The law requires us to keep your protected health information (PHI) private in accordance with this Notice of Privacy Practices (Notice) as long as this Notice remains in effect. We are also required to provide you with a paper copy of this notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI.
From time to time, we may revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable laws. Such revisions to our privacy and our Notice may be retroactive. Our Notice will be updated and made available to our patients prior to any significant revisions of our privacy practices and policies.
Use and Disclosure: We may use or disclose your PHI for treatment, payment or health care operations. For your
convenience, we have provided the following examples of such potential uses or disclosures.
Treatment: Your PHI may be used by or disclosed to any physicians or other health care providers involved with the
medical services provided to you.
Payment: Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.
Health Care Operations: Your PHI may be used or disclosed as part of our internal health care operations. Such health
care operations may include among other things, quality of care audits of our staff and affiliates, conducting training programs, accreditation, certification, licensing or credentialing activities.
Authorizations: We will not use or disclose your medical information for any reason except those described in this
Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you, may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.
Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this
Notice. With your permission, or in some emergencies, we may disclose your PHI to your family members, friends, or other people to aid in your treatment or the collection of payment. A disclosure of your PHI may also be made if we determine it is reasonably necessary
Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in
Required by Law: We may use or disclose your medical information when we are required to do so by law. For
example, your PHI may be released when required by privacy laws, workers’ compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody.
Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or
organ procurement organization in limited circumstances.
Research: Your PHI may also be used or disclosed for research purposes only in those limited circumstances not
requiring your written authorization, such as those that have been approved by an institutional review board that has established procedures for ensuring the privacy of PHI.
Military and National Security: We may disclose to military authorities the medical information of Armed Forces
personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence, and other national security activities.
Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI by requesting access or
copies in writing to our Privacy Officer. Please contact our Privacy Officer regarding our copying fees.
Disclosure Accounting: You have the right to receive an accounting of the instances, if any, in which your PHI was
disclosed for purposes other than those described in the following sections above: Use and Disclosures, Patient access, and Locating Responsible Parties. For each 12-months, you have the right to receive one free copy of an accounting of certain details surrounding such disclosures that occurred after your initial visit. If you request a disclosures accounting more than once in a 12-month period, we will charge you a reasonable, cost based fee for each additional request. Please contact our Privacy Officer regarding these fees.
Additional Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of
your PHI, but we are not required to honor such a request. We will be bound by such restrictions only if we agree to do so in writing signed by our Privacy Officer.
Alternate Communications: You have the right to request that we communicate with you about your PHI by alternative
means or in alternative locations. We will accommodate any reasonable request if it specifies in writing the alternative means or location, and provides a satisfactory explanation of how future payments will be handled.
Amendments to PHI: You have the right to request that we amend your PHI. Any such request must be in writing and
contain a detailed explanation for the requested amendment. Under certa
Complaints: If you believe we have violated your privacy rights, you may complain to us or to the Secretary of the U.S.
Department of Health and Human Services. You may file a complaint with us by notifying our Privacy Officer.
We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
I hereby authorize any health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription history clearing house, consumer reporting agency, employer, and family member to release all health information about me.
The following person/organization is hereby authorized to receive my entire medical record, treatment record and diagnostic record:
Vitality Wellness 280 Adriatic Parkway McKinney, TX 75070 Phone: (972) 332-0971
By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my health does not apply to this authorization. The following health information that relates to service may be released: Entire Medical Record including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent by other health care providers. I further understand that my medical record may include one or more of the following: Treatment of communicable diseases, including sexually transmitted diseases, venereal diseases, tuberculosis, or hepatitis, HIV-Related Treatment, Mental Health Information or Psychological Conditions, Alcohol or Substance Abuse Treatment, Genetic Testing
I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.
A copy, electronic copy, image, or facsimile of this authorization is as valid as the original. I have the right to revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the extent the above p
Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.
I voluntarily request the physician(s) and such associates, clinical staff, technical assistants and other health care providers as they may deem necessary (“Vitality Telemedicine Providers”) to participate in my medical care through the use of telemedicine.
I understand that Vitality Telemedicine Providers may practice in a different location than where I present for medical care, may not have the opportunity to perform an in-person physical examination, and rely on information provided by me. I acknowledge that Vitality Telemedicine Provider’s advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as a result or cure.
If Vitality Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communicas