Complete New patient paperwork Dr. Juarez

CLINIC POLICIES & PROCEDURES

Please read thoroughly
Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name

Acknowledgement & Requested Restrictions
By signing below, you acknowledge that you have received the notice of privacy practices prior to any service being provided to you by the practice and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below. The Notice of Privacy Practices is available online or a copy may be emailed to you or you may review the paper copy in the clinic.
I hereby request the following restrictions on the use and / or disclosure (specify as applicable) of my information:
Signature*

Clear
Date*

MonthDayYear
Date
Name*

First NameLast Name
If legal representative, relationship to the patient: blanks

Preferred Pharmacy Information
Preferred LOCAL PHARMACY blanks*
Address (if available) and phone number: blank*
Mail Order Pharmacy (if applicable): blanks

TELEMEDICINE CONSENT
Introduction
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of
the following:
 Patient medical records
 Medical images
 Live two-way audio and video
 Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
 Improved access to medical care by enabling a patient to remain in his/her phycisian office (or at aremote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
 More efficient medical evaluation and management.
 Obtaining expertise of a distant specialist.

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of telemedicine.
These risks include, but may not be limited to:
 In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
 Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
 In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
 In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My ophthalmologist has explained the alternatives to my satisfaction.
5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
6. I understand that it is my duty to inform my ophthalmologist of electronic interactions regarding my care that I may have with other healthcare providers.
7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions
have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize Dr. Juarez to use telemedicine in the course of my diagnosis and treatment.
Signature*

Clear
Name

First NameLast Name
Date*

MonthDayYear
Date

Patient Contact Consent Form
To comply with the Telephone Consumer Protection Act (TCPA) our office is required to receive consent for sending appointment reminders and messaging by SMS mobile texting or voice telephone calls.

Please indicate your consent below by checking the box by each statement you agree with and then select which method of communication you prefer.

If you have any questions please call Partners in Endocrinology at (713) 929-0043.

You may update and/or change your preference of how to contact you at anytime by completing a new consent form or by putting your request in writing and submitting it to Partners in Endocrinology
Preferred method of communication SMS mobile texting reminders and messaging (choose all that apply).*

SMS Mobile textingVoice reminders & messagingEmailDecline consent
Signature

Clear

RECORDS RELEASE AUTHORIZATION
Please read this entire form before signing and complete all the
sections that apply to your decisions relating to the disclosure
of protected health information. Covered entities as that term is
defined by HIPAA and Texas Health & Safety Code § 181.001 must
obtain a signed authorization from the individual or the individual’s
legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for
disclosures related to treatment, payment, health care operations,
performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other
form that complies with HIPAA, the Texas Medical Privacy Act, and
other applicable laws. Individuals cannot be denied treatment based
on a failure to sign this authorization form, and a refusal to sign this
form will not affect the payment, enrollment, or eligibility for benefits

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Dr. Jyothi Mamidi Juarez- Partners in Endocrinology

350 N. Texas Ave. Suite A-2

Webster, TX 77598

fax: 713-929-0044

phone: 281-619-7092

Reason for request: Ongoing medical care.

What information can be disclosed: The last 2 clinic notes, last 2 sets of labs, any pertinent Endocrine related imaging or other specified request below.

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional): Month _________ Day __________ Year _________
RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.” I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 C.F.R. § 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION. Include name of clinic or doctor and phone number. *
Signature (or legal representative)*

Clear
Date*

MonthDayYear
Date
Name (or legal representative)*

First NameLast Name
Should be Empty:

PARTNERS IN ENDOCRINOLOGY- DR. JYOTHI MAMIDI JUAREZ

INSURANCE INFORMATION

SOCIAL HISTORY

MEDICATIONS

Review of Systems

CLINIC POLICIES & PROCEDURES

Acknowledgement & Requested Restrictions

Preferred Pharmacy Information

TELEMEDICINE CONSENT

Patient Contact Consent Form

RECORDS RELEASE AUTHORIZATION