Attach to Your Paperwork€¦ · 22/06/2020 · my consent, SMSWLC and/or it’s delegates may...

Attach to Your Paperwork

In order to process your paperwork and verify your insurance benefits, we request that

you please include a copy of:

• The front of your insurance card

• The back of your insurance card

• Your driver’s license

License Front & Back of Insurance Card

Return Your Paperwork

You can submit this paperwork via:

• Fax: (228) 818-3978

• Email: [email protected]

Prepare for Your Visit

Each time you come to our office for an appointment you will have to remove your socks and shoes for our Tanita scale to measure your body mass index (BMI). You may want to wear shoes and socks that are easy on – easy off.

Revised: 02/26/20 AK 2

BEFORE YOU COMPLETE AND SUBMIT THIS PAPERWORK:

You are required to finish the FREE webinar or in-person seminar before

submitting this packet.

________ Please check here to confirm that you have finished the online webinar or attended an in-person seminar.

If you have not completed the online webinar or attended an in-person seminar, go to www.smsurgicalweightloss.com to get started. Once you finish either one of those, you can submit this paperwork.


Patient Information Referring Doctor: ______________________________________ Language Choice: _______________________________

Pharmacy: ____________________________________________ Pharm City/State: _______________________________

Last Name: ______________________________ First Name: ______________________________________ MI: _______

Street Address: _______________________________ City: _______________________ State: ___________ Zip: ___________

Mailing Address: _______________________________ City: _______________________ State: ___________ Zip: ___________

Home Phone #: __________________________ Work #: ___________________________ Cell #: ____________________________

Date of Birth: _________________________ SSN: ___________________________ Gender: ___________________

Marital Status: __________________________ Spouse’s Name: __________________________________________

Emergency Contact ______________________________ Relation _________________________ Phone #: _________________

That does not live with you.

Do we have your permission to:

Leave a message on your cell phone? ______ Yes ______ No ______ N/A

Leave a message on your home answering machine? ______ Yes ______ No ______ N/A

Leave a message at your place of employment? ______ Yes ______ No ______ N/A

Can we email about appointments or medical condition? ______ Yes ______ No ______ N/A

E-mail Address: _____________________________________________

Can we discuss medical condition with household or family members? ______ Yes ______ No If Yes, please list:

Name: ____________________ Relation: _________________ | Name: _____________________ Relation: _________________

Name: ____________________ Relation: _________________

Guardian Information for Minor Patients

Relationship: ___________________ Last Name: ________________________ First Name: __________________ MI: _____

Birth Date: _________________ SSN: __________________________ Home #: __________________ Work #: ____________

Address: ____________________________________ City: ______________________ State: __________ Zip: _____________

Insurance Information MEDICARE #: _________________

Please include a copy of the front and back of your insurance card and driver’s license MEDICAID #: _________________

PRIMARY INSURANCE SECONDARY INSURANCE Insured Name: ______________________________________ Insured Name: ___________________________________

Relationship to Patient: _______________________________ Relationship to Patient: ____________________________

Date of Birth: _______________________________________ Date of Birth: _____________________________________

Insurance Company: _________________________________ Insurance Company: _______________________________

SSN: _______________________________________________ SSN: _____________________________________________

Group #: ___________________________________________ Group #: _________________________________________

Policy #: ___________________________________________ Policy #: __________________________________________

Employer Name: ____________________________________ Employer Name: ___________________________________

Employer Address: ___________________________________ Employer Address: _________________________________

__________________________ ______________________________________________ Date Patient Signature

__________________________ ____________

MEDICAL HISTORY FORM

Patient: __________________________ Date of Birth: ____________


Patient Information and Demographics

Date: ___________________ Race: ________________ Age: ________________ Height: ______________

Current Weight: _____________ Weight Loss Goal: __________________________

Surgery/Program you plan to participate in:

______ Low BMI Sleeve Gastrectomy (BMI 30-34.9) ______ Orbera Balloon

______ Non-Surgical Weight Management ______ Roux-en-Y Bypass

______ Sleeve Gastrectomy

How did you hear about our program? ____________________________________________________________

Occupation: ____________________________________________________

Education:

______ Grade School ______ High School ______ Some College ______ College Degree ______ Post Grad

Are you currently under the care of a Family Physician? ______ Yes ______ No

Name: ______________________________________ Address: ______________________________________

City/State/Zip : __________________________________ Phone: ________________________

Fax: ______________________ May we contact him or her? ______ Yes ______ No

Are you under the care of a Mental Health Professional? ______ Yes ______ No

Name: ______________________________________ Address: ______________________________________

City/State/Zip : __________________________________ Phone: ________________________

Fax: ______________________ May we contact him or her? ______ Yes ______ No


Patient: __________________________

Date of Birth: ____________


Past Medical History/Review of Systems Please indicate if you have ever been diagnosed with any of the following medical problems.

_____ Abdominal Hernia

_____ Barrett’s Esophagus

_____ Gastrointestinal Esophageal Reflux Disease

(GERD)

_____ Crohn’s Disease

_____ Hepatitis

_____ Liver Disease

_____ Anemia

_____ Chronic Kidney Disease/Renal Insufficiency

_____ Kidney stones

_____ Arthritis/Degenerative Joint Disease

_____ Osteoporosis

_____ Chronic Obstructive Pulmonary Disease

(COPD)

_____ Emphysema

_____ Asthma

_____ Bronchitis

_____ Pulmonary Hypertension

_____ Seizures

_____ Implantable Heart Device (Defibrillator, etc.)

_____ Coronary Artery Disease

_____ Heart Attack

_____ Stroke

_____ Heart Valve Disease

_____ Peripheral Vascular Disease (PVD)

_____ Congestive Heart Failure (CHF)

_____ Heart Murmur

_____ Deep Vein Thrombosis (DVT)

_____ Pulmonary Embolism (Blood Clot in lung)

_____ Cancer? Where?*

*_____________________________

_____ Lupus or any Autoimmune Disorder

_____ Thyroid problems (Hypo/hyperthyroid)

_____ Irregular periods

_____ Polycystic Ovarian Syndrome (PCOS)

_____ Gestational Diabetes

_____ Type 1 Diabetes

_____ Mental Illness?

If yes, please indicate diagnosis:

_________________________________

Other: ___________________________

Co-Morbid Conditions Associated with Obesity * Please mark “yes” or “no.” If yes, please list any medications you take for the condition: High Blood Pressure _____ Yes _____ No _________________________________________

High Cholesterol _____ Yes _____ No _________________________________________

Pre-diabetes/Insulin Resistance _____ Yes _____ No _________________________________________ Type 2 Diabetes? _____ Yes _____ No _________________________________________

If yes, do you take insulin? ______ Yes ______ No

Obstructive Sleep Apnea? _____ Yes _____ No _________________________________________

Do you or should you use a BiPAP or CPAP machine? ______ Yes ______ No


Patient: __________________________ Date of Birth: ____________


Have you experienced any of the following symptoms within the past six months?

_____ Abdominal Pain

_____ Abnormal Chest X-ray_____ Abnormal Range of Motion_____ Back, Hip, or Leg Pain_____ Constipation_____ Diarrhea_____ Difficulty Breathing at Night _____ Difficulty Swallowing_____ Easy Bruising

_____ Excessive Sweating_____ Excessive Thirst _____ Fatigue_____ Heat/Cold Intolerance_____ Excessive Thirst

_____ Indigestion

_____ Joint Stiffness_____ Muscle Weakness_____ Nausea_____ Night Sweats_____ Numbness or Tingling of Extremities _____ Rapid Heartbeat_____ Recurrent Pneumonia

_____ Shortness of Breath_____ Shortness of Breath with Exertion

_____ Snoring

_____ Sores or Ulcers of the Skin_____ Swelling in Extremities (Edema)_____ Vomiting_____ Wheezing

Please Answer the Following:

1. Do you currently or have you ever been diagnosed with Schizophrenia? _____ Yes _____ No

2. Do you currently or have you ever been diagnosed with an eating disorder? _____ Yes _____ No

3. Are you currently pregnant or plan on becoming pregnant within the next 1 year? _____ Yes _____ No

4. Do you receive dialysis for kidney disease? _____ Yes _____ No

5. Are you currently diagnosed with cancer and receiving treatment? _____ Yes _____ No

6. Are you currently on an organ transplant list? _____ Yes _____ No

7. Do you require use of a walker, wheelchair, or scooter? _____ Yes _____ No

8. Is there any reason you would NOT consent to a blood transfusion or blood products for life-saving

reason? _____ Yes _____ No

9. Have you ever experienced complications with anesthesia? _____ Yes _____ No


Patient: ________________________ _________________________

Date of Birth: _______________


Medications

Do you take a blood thinner? ______ Yes ______ No

IF YES: Which Medication: _________________________________ Reason: ________________________

How long have you taken them? _______________________________________

Do you take steroids? ______ Yes ______ No

IF YES: Which Medication: _________________________________ Reason: ________________________

How long have you taken them? _______________________________________

Have you ever been told you need antibiotics to protect your heart before you have surgery? ___Yes ___No

IF YES: Which Medication: __________________________ Reason: __________________________

Other Prescriptions, Vitamins/Minerals, Herbal Supplements, or Over-the-Counter Drugs Currently Taken

MEDICATION DOSE HOW MANY TIMES A DAY REASON

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

____________________ ____________ __________________________ _______________________________________________

Allergies – List Drug, Food, or Material Allergies

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


Patient: ________________________ _________________________

Date of Birth: _______________


Past Surgical History

Have you ever had any previous weight loss procedure? ______ Yes ______ No

IF YES: Surgery Type: ___________________________________________ Year: ___________

Surgeon: _____________________________________

Highest Pre-Surgery Weight: __________________ Lowest Post-Surgery Weight: ________________

How long did you maintain your weight loss? _______________________________________________

Have you ever had a heart cath? ______ Yes ______ No

IF YES: Year: ______________ Reason: ________________________________________________

Did it require a stent? ______ Yes ______ No

Have you ever had a colonoscopy? ______ Yes ______ No

IF YES: Year: ________________ Reason: _______________________________________________

Have you ever had an EGD (Where a camera looks into your stomach)? ______ Yes ______ No

IF YES: Year: ________________ Reason: _______________________________________________

Have you ever had a mammogram? ______ Yes ______ No

IF YES: Year: _______________

Surgeries - List any other surgeries.

Surgery Date

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________

__________________________________________________________________ ____________________


Patient: ________________________ _________________________

Date of Birth: _______________


Medical Weight Loss History

Please check or list AT LEAST FOUR of the following programs you have tried in an attempt to lose weight:

______ Diet Pills by MD

______ Diet Shots by MD

______ Supervised Calorie Counting by a Healthcare Professional

______ OPTIFAST®

______ Weight Watchers®

______ NutriSystem®

______ Atkins Diet®

______ Sugar Busters®

______ Low Fat

______ Mayo Clinic

______ Health Management Resources

______ TOPS®

______ Overeaters Anonymous®

______ Grapefruit Diet

______ Keto Diet

______ Richard Simmons

______ Calorie Counting on Own

______ Slim Fast®

______ Other (Please Type): _________________________________________________

_______________________________________________________________

_______________________________________________________________


Patient: ________________________ _________________________

Date of Birth: _______________


Nutritional, Dieting, and Exercise History

How long have you been overweight? ___________________________

At what age were you first overweight by 10 pounds or more? _________________

Is this the first time you have been evaluated for weight loss surgery? _____ Yes ______ No

What is your worst diet habit? __________________________________________________________________

In the past, what has been your best weight loss method? ____________________________________________

My all-time highest weight was __________ pounds at _________ years old.

Social History

Do You Smoke/vape? ______ Yes _______ No If you once smoked when did you quit? _________

Frequency of Use: ______ Rarely _______ Occasionally _______ Frequently

Do you drink alcohol? ______ Yes _______ No If you once drank, when did you quit? ______________


Have you or are you addicted to prescription or illegal drugs? ______ Yes _______ No

If so, what? ____________________________________ How long? _______________________________


Please check if appropriate:

Obesity

Family History

Diabetes

Hypertension

Cardiac Disease

Sudden Death

Cancer

If you have a family history of cancer, please specify what type:

____________________________________________________

Mother Father Sister Brother







Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 10

AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS

FROM SOUTH MISSISSIPPI SURGEONS

Date: _______________________________________

Patient Name: ________________________________________________

Patient Address: __________________________________________________________________

City: ______________________________ State: _____________ Zip: ______________________

Date of Birth: __________________________________ Social Security #: _____________________________

I, , hereby authorize: SOUTH MS SURGICAL WEIGHT LOSS CENTER TO RELEASE COPIES OF MEDICAL RECORDS ON THE ABOVE INDICATED PATIENT.

_____________________________________

Patient Signature

______ (INITIALS) Protected information: By signing here I understand that medical records released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse. I understand that such information is protected by federal law and will not be shared with anyone unless authorized separately.


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 11

AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS

TO SOUTH MISSISSIPPI SURGEONS

Date: _______________________________________

Patient Name: ________________________________________________

Patient Address: __________________________________________________________________

City: ______________________________ State: _____________ Zip: ______________________

Date of Birth: _________________________________ Social Security #: _____________________________

I, , hereby authorize to release copies of medical records on the above indicated patient to SOUTH MS SURGICAL WEIGHT LOSS CENTER.

_____________________________________

Patient Signature

(INITIALS) Protected information: By signing here I understand that medical records released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse. I understand that such information is protected by federal law and will not be shared with anyone unless authorized separately.


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 12

Consent for Treatment

This consent is not to be used or considered an informed consent for operation or surgical procedures. This is to certify that the undersigned authorizes the examination and/or treatment as may be necessary or advisable completed within the office of South Mississippi Surgical Weight Loss Center, LLC (SMSWLC).

1. I consent to my photograph to be taken by SMSWLC for identification and documentation purposes.

2. The undersigned as the patient or his/her authorized legal representative do hereby authorize SMSWLC torelease to my insurance company or other appropriate agencies, information necessary to validate this claimfor billing purposes.

3. SMSWLC is also hereby authorized to release to any other physicians or medical entity information as neededfor treatment, care of the insured.

4. I hereby authorize any medical and/or health insurance company to pay the proceeds of any benefits due medirectly to SMSWLC. A copy of this form can be considered as an original for insurance purposes. I acknowledgeand understand that I am responsible for all of the charges for all of the services rendered to me or the indicatedperson for whom I am financially responsible. Although I have requested the doctors to bill my insurancecompany on my behalf, I clearly understand that it is still my responsibility to make sure the bill is paid in areasonable time. If for any reason any portion of my bill is not paid by my insurance company, I further agreeto make arrangements for prompt payment of the bill.

5. I have read this agreement and understand the contents.

____________________________ _______________________ _______________________________________

Patient Name (Print) Date Patient Name (Signature)

____________________________ _____________ ______________ _______________________________________

Responsible Party Name (Print) Relationship Date Responsible Party Name (Signature)

6. Statement to Permit Payment of Medicare/Medicaid Benefits to SOUTH MISSISSIPPI SURGEONS, P.A.

_______________________ and/or __________________________ _______________________________ Medicare # Medicaid # Beneficiary

I request that payment of authorized MEDICARE/MEDICAID benefits be made on my behalf to SMSWLC for services furnished me by physicians associated with SMSWLC. I authorize SMSWLC to release Health Care Financing Administration or Medicaid and its agents any information needed to determine these benefits or the benefits payable for related services.

______________________________________________

Patient/Responsible Party Signature


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 13

Financial Policy

Thank you for choosing South Mississippi Surgical Weight Loss Center, LLC (SMSWLC) as your healthcare provider. We are committed to providing you the best possible service at the lowest possible price. Following is a statement of our financial policy which we require you to read and sign prior to treatment.

SMSWLC accepts payment for professional services in the form of cash, check, credit card or patient financing. All patients will be required to establish a financial arrangement when services are rendered. In addition, we accept insurance from major insurance companies. PLEASE BE AWARE THAT FEW INSURANCE COMPANIES ATTEMPT TO COVER ALL MEDICAL COSTS. EACH PATIENT IS REQUIRED TO MAKE A DEPOSIT PRIOR TO SURGERY. Your insurance coverage is a contract between you and your insurance carrier. We will assist you in maximizing your insurance benefits and in obtaining necessary pre- certifications. As a courtesy we will review your insurance coverage, estimate your insurance payment, review your insurance form and file your claim with the carrier. To avoid any misunderstanding, we will require you to assign all insurance benefits for professional services directly to our office. If you request your insurance company to pay you directly, we will require full payment from you at the time of service. You will be notified when the insurance carrier remits payment to our practice. We will apply this payment to your account and refund any credit balance within 30 days.

If an insurance problem occurs you will be asked to assist us in contacting your insurance carrier. We feel it is necessary to work together to resolve any insurance problem. YOU WILL BE RESPONSIBLE FOR ANY PORTION OF YOUR BILL WHICH IS DENIED OR NOT PAID BY YOUR INSURANCE CARRIER.

If this bill is not paid within the ninety (90) day period from demand or billing, SMSWLC may add a collection fee of up to 30% or $10.00 whichever is higher. If the account is turned over to a collection agency or attorney, a 30% fee will be added to the account.

Our practice firmly believes that a good doctor/patient relationship is based upon understanding and good communication. Our staff has been instructed to make every effort to clarify any misunderstandings you have concerning your balance. If you have any questions concerning our financial policy or need any assistance, please contact our practice immediately at 769-2069.

I have read, understand, and agree to the financial policy.

__________________________________________ __________________________

Signature of Patient or Responsible Party Date


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 14

Authorization to Obtain Medication History

Patient Name: ________________________________________________

Patient Address: __________________________________________________________________

City: ______________________________ State: _____________ Zip: ______________________

Date of Birth: _________________________________ Social Security #: _____________________________

By signing below, I hereby authorize South Mississippi Surgical Weight Loss Center, LLC to obtain Medication

History related to the patient above, from Community Pharmacies and/or Pharmacy Benefit Managers for the

purpose of Continued Treatment.

_________________ _________________________ _________________________ Authorization Date Print Name of

Patient/Legal Representative or Parent/Legal Guardian

Signature of Patient/Legal Representative or

Parent/Legal Guardian

I understand that this authorization is revocable upon written notice to the office where the original authorization

is retained, except to the extent that action has already been taken on this authorization. South Mississippi

Surgical Weight Loss Center, LLC may not condition the provision of treatment, payment, enrollment in the health

plan, or eligibility for benefits on the provision of this authorization.


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 15

Marketing Consent and Disclosure

I understand that by providing this marketing consent to South Mississippi Surgical Weight Loss Center (SMSWLC) and/or its delegates, I am allowing these parties to use my images, name, related weight loss information, and related co-morbid condition information to promote SMSWLC. I understand that by providing my consent, SMSWLC and/or it’s delegates may post my name, type of surgery, weight loss statistics, physician who performed my surgery, and images on platforms, including without limitation, Facebook, Twitter, Pinterest, YouTube, and/or Google+, on its internet site, and may use such information in print or other published marketing materials promoting SMSWLC. I am aware of the public disclosure of my surgery by providing my permission hereunder to use my information and images.

I also understand the following:

SMSWLC reserves the right to monitor, prohibit, restrict, block, suspend, terminate, delete, or discontinue your content to our marketing platforms at any time, without notice, and for any reason and in its sole discretion. SMSWLC and/or its affiliates cannot be held liable for comments made with regard to my images or information. Consent to use my information and images is not consent to post or otherwise disclose any other personal medical information about me.

This consent will expire upon the discontinuance by SMSWLC of any marketing efforts through any marketing platforms, the internet, or printed marketing materials. I understand that I may revoke this consent in writing at any time sending such written revocation to SMSWLC at the address set forth above and to the attention of the Program Director. A reasonable time lag may exist while my revocation is processed and before the information and images are removed from applicable marketing platforms or internet sites and that my information and images cannot be removed from any previously published materials such as marketing brochures already printed and in circulation. Additionally, SMSWLC cannot be responsible for copied, shared and distributed content through the channels of social networks and the internet. Accordingly, due to the risk of redisclosure by others of my information once posted to any marketing or any internet site, such information will no longer be protected by 45 CFR § 164.508 under HIPAA. It is my responsibility to contact site owners wherein images have been compromised and/or reposted to request removal of my images. SMSWLC may not condition any treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

I have read, understand and agree to this marketing consent and disclosure.

_________________________________________________________ _______________________________ Signature of Patient or Responsible Party Date


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 16

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION South Mississippi Surgical Weight Loss Center, LLC (‘SMSWLC’) is dedicated to protecting your health information. We understand that health information about your health is personal and we are committed to protecting health information about you. This Notice applies to all of the records of your care generated by this office, whether made by your personal doctor or others working in this office. This notice will inform you of the ways in which we may use and disclose your health information. It describes your rights to the health information and certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

Make sure that health information that identifies you is kept private

Give you this Notice of our legal duties and privacy practices with respect to Health Information about you

Follow the terms of the Notice Of Privacy Practices for the Protected Health Information

Permitted and required uses and disclosures:

For treatment

For Payment including but not limited to, your insurance, self-funded or third-party health plans

For Health Care Operations

For appointments, automated appointment reminders and referrals

As required by Law

To avert a serious threat to health and safety

As required by Workers Compensation, Military or Veterans Affair

Public health risks

Health care oversight activities such as audits, investigations and inspections

Lawsuits and disputes

Law enforcement, National Security and intelligence activities

Coroners, health examiners and funeral directors

Security Officials for Inmates

You have certain rights regarding Health Information about you:

Right to request restrictions

Right to confidential communications

Right to inspect and obtain paper copies. (SMSWLC charges a reasonable cost-based fee for paper copies.)

Right to amend

Right to accounting of disclosure

Right to copy of this Notice (full notice is available upon request)

Right to receive notification of any breach

We reserve the right to change this notice. In the event of changes to this Notice, we will place a current Notice in our Facility with the changes and have you sign a new acknowledgement of receipt of the notice.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or to the Secretary of the U.S. Department of Health and Human services. All complaints must be in writing.

Acknowledgement of Receipt of this Notice: SMS requires you to sign a separate form acknowledging you have received a copy of this Notice. This Acknowledgement becomes a part of your record.


Patient: ________________________ _________________________

Date of Birth: _______________

Revised: 02/26/20 AK 17

ACKNOWLEDGEMENT FORM for: Notice of Privacy Practices for Protected Health Information.

I HAVE READ AND HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS CONCERNING THIS NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION.

Patient or Patients Representative

Date

SMS MANAGEMENT, LLC AND SMSWLC, LLC POLICY ON USE OF RECORDING DEVICES BY PATIENT IN OUR OFFICES

I. To ensure confidentiality and privacy, any type of electronic recording is strictly prohibited within our offices at anyof our locations. This includes any audio/video equipment or use of cell phones for recording purposes.

A. The Health Insurance Portability and Accountability Act (HIPPA) grants privacy protection to patient’srecords. Once a recording is made, it may be hard to ensure that it remains private.

B. Electronic recording infringes on the privacy rights of the physician and employees.

C. If it is discovered that you have electronically recorded any of the SMS/SMSWLC staff, or any other patientsin our office, we will withdraw you from our care. You are expected to abide by our policy while you are on ourpremise’s. Your understanding and compliance to this policy will be greatly appreciated.

________________________________________ ____________________________________ Patient Signature Date

Attach to Your Paperwork€¦ · 22/06/2020 · my consent, SMSWLC and/or it’s delegates may...

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Transcript of Attach to Your Paperwork€¦ · 22/06/2020 · my consent, SMSWLC and/or it’s delegates may...