List physicians (past and present) and their specialty:
Please tell us the health of your family. Are your parents living? If so, what are their ages and list any medical problems they may have including diabetes, high blood pressure, heart attacks, strokes, cancers. If they are deceased, please list their age at death and the cause if known.
If you are female, when was your last:
Are you affected by any of the following conditions? If so, please give the duration and explain.
Thank you for taking your time to answer these questions.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.
consent to the use or disclosure of my protected health
information by Jupiter concierge Family Practice, Inc. for the purpose of diagnosing or providing treatment for me, obtaining payment for my healthcare bills, or to conduct healthcare operations of Jupiter Concierge Family Practice, Inc. I understand that diagnosis or treatment of me by Dr. David C. Rosenberg may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Jupiter Concierge Family Practice is not required to agree to the restrictions that I request. However, if Jupiter Concierge Family Practice agrees to a restriction that I request, the restriction is binding to our physician.
I have the right to revoke this consent in writing at any time, except to the extent that Jupiter Concierge Family Practice or David C. Rosenberg has taken action in reliance on this consent.
My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer, or a healthcare billing clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis the information may identify me.
I understand I have the right to review Jupiter Concierge Family Practice’s Notice of Privacy Practices prior to signing this document, which has been provided me. The notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in treatment, payment of my bills or in the performance of healthcare operations of Jupiter Concierge Family Practice. The Notice of Privacy Practices for Jupiter Concierge Family Practice is also provided at the front desk, which describes my rights and Jupiter Concierge Family Practice’s duties with respect to my protected health information.
Jupiter Concierge Family Practice reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices.
I authorize Jupiter Concierge Family Practice to check my prescription history.