PATIENT’S RIGHTS AND RESPONSIBILITES

As a patient you have certain rights and responsibilities. We recognize that a respectful relationship between the healthcare provider and the patient is the foundation of proper medical care.

Patients have the right to:

Receive humane care and treatment, with respect and consideration.
Privacy and confidentiality when seeking or receiving care except for life threatening conditions or situations.
Confidentiality of your health records.
Be informed of and to exercise the option to refuse to participate in any research aspect of your care without compromising access to medical care and treatment.
Receive accurate information concerning diagnosis, treatment, risks involved, and prognosis of an illness or health related condition.
Ask about reasonable alternatives to care.
A second professional opinion regarding one’s health care and treatment.
Participate actively in decisions regarding one’s health care and treatment.
Participate actively in decisions regarding one’s health care and treatment.
Accessible information regarding the scope and availability of services.
Be informed about any legal reporting requirements regarding any aspect of screening or care.

Patients have the responsibility to:

Provide complete information about one’s illness/problem, to enable proper evaluation and treatment.
Ask questions so that an understanding of the condition or problem is ensured.
Show respect to health personnel and other patients.
Reschedule/cancel an appointment in a timely manner so that another person may be given that time slot.
Pay bills or file health claims in a timely manner.
Use prescription or medical devices for oneself only.
Inform the practitioner(s) if one’s condition worsens, or an unexpected reaction occurs from a medication.

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Date :

Advance Practice Nurse/Nurse Practitioner Consent for Treatment

This office has an Advance Practice Nurse and/or Nurse Practitioner (to be referred to herein as Advance Practice Nurse) on staff to assist in the delivery of medical geriatric care.

An Advance Practice Nurse is not a doctor but is under the direct supervision of the physician. An Advance Practice nurse is a registered nurse who has received advanced education and training in provision of health care. An advance practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, the advance practice nurse may treat minor lacerations and other minor injuries.

I have read the above and hereby consent to the services of an advance practice nurse for my health care needs.

I understand that at any time I can refuse to see the advance practice nurse and request to see a physician.

Patient’s Signature or Responsible Party*:

Date :

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Name* :

Date :

General Consent for Care and Treatment Consent

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Patient’s Signature or Responsible Party*:		Date :
Printed Name of Patient or Personal Representative*		Relationship to Patient* :

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NOTICE AND AUTHORIZATION OF PRIVACY PRACTICES

Healthcare providers are required by federal and state laws to maintain the privacy of “Protected Health Information” (PHI) and to provide you with notice about your rights and our legal duties and privacy practices with respect to your PHI. We must abide by the terms of this Notice while it is in effect. Some of the uses and disclosures described in this Notice may be limited in certain causes by applicable state laws that may be more stringent than the federal standards. This Notice is effective as of April 14, 2003. PHI is information about you, including demographic information that can be reasonably used to identify you and that relates to your past, present, or future physical or mental health or condition, the provision of related health care services to you or the payment for that care. This Notice tells you about the ways in which we may collect, use and disclose your PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. Your rights concerning your PHI are also discussed in this Notice. Once you sign Fort Bend Geriatrics consent/authorization form, we may use and disclose your medical information to treat you, to obtain payment, and to operate the practice. The practice may use or disclose your protected health information only with your written authorization. You may revoke authorization in writing at any time, except to the extent of PHI already disclosed. The practice may use or disclose protected health information about you for other purposes and without your consent if the law requires us to disclose information to government authorities.
You have the following rights regarding your protected health information, and the practice must act on your request within 60 days:

You may request restrictions on certain uses and disclosures of protected health information, but we are not required to agree to a requested restriction.
You may request that you receive confidential communication of protected health information.
You may request to inspect and copy your own projected health information.
You may request that your information be amended.
You may request a paper copy of this notice.

The law requires the practice to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices. The law requires the practice to abide by the terms of this notice and to provide individuals with notice revisions. You may complain to the practice or to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. A complaint can be filed with this practice by writing to: Fort Bend Geriatrics, 16605 Southwest Freeway, Suite 175, Sugar Land Tx, 77479.

I have read the Notice of Privacy Practices from Fort Bend Geriatrics. I understand that my Protected Health Information may be used by Fort Bend Geriatrics for the purposes of: Payment, Operations, and Treatment. I also understand that this information may be released to “Business Associates” for the same purposes. I also understand that I have the right to refuse to sign this authorization form. I understand that if I refuse to authorize the release of my health information, Fort Bend Geriatrics my not refuse to treat me.

I understand that in order to provide the most effective medical diagnosis and treatment, it may be necessary for my attending physician to discuss my medical condition with certain family members or caregivers. My signature below gives my permission for my physician to discuss my medical condition with the following family members or caregivers if such communication is deemed necessary.

Name *:
Home #*:
Work #:
Cell #:
Relationship to Patient* :

Name :
Home #:
Work #:
Cell #:
Relationship to Patient:

Patient’s Signature or Responsible Party *:

Date :

PREVIOUS SUBMIT

PATIENT’S RIGHTS AND RESPONSIBILITES

Advance Practice Nurse/Nurse Practitioner Consent for Treatment

General Consent for Care and Treatment Consent

PATIENT INFORMATION

BILLING ADDRESS

IN CASE OF EMERGENCY, NOTIFY:

SECONDARY INSURANCE INFORMATION OR IF MEDICARE IS NOT PRIMARY- PLEASE COMPLETE:

MEDICARE AND INSURANCE ASSIGNMENT AND RELEASE

PATIENT HISTORY

PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING MEDICAL DIAGNOSIS OR CONDITIONS:

PLEASE PROVIDE LIST OF SURGERIES WITH DATE IF ANY:

FAMILY HISTORY

SOCIAL HISTORY

FUNCTIONAL STATUS

Pharmacy

CURRENT MEDICATIONS LIST

NOTICE AND AUTHORIZATION OF PRIVACY PRACTICES