WELCOME

LANG FAMILY MEDICINE DOES NOT FILE ANY INSURANCE, INCLUDING MEDICARE.

Although we do not file medical insurance or Medicare, we still work closely with pharmacies, outside labs, and imaging clinics that may take your coverage. 

IF YOU CHECK THIS BOX, PLEASE PROCEED TO FILL OUT THE FORM BELOW.

We may need to send you outside of our clinic for various testing, labs, x-rays or other types of imaging.  We may also need to provide referrals to other medical offices or pharmacies on your behalf.

In order to do this efficiently and as quickly as possible, we may need to give the name of your insurance company to any of the above-mentioned entities.  If applicable, please provide us with the following information:

If your medical insurance changes at any time, please let us know so that we can let you update your insurance information.

PLEASE NOTE: BY SIGNING THIS DOCUMENT YOU AGREE THAT YOU ARE RESPONSIBLE FOR ALL CHARGES INCURRED BY SERVICES RENDERED.

IF YOU HAVE MEDICARE YOU MUST SIGN THIS FORM IN ORDER TO BE SEEN AT OUR OFFICE

This agreement is between Dr. Howard J. Lang, and Dr. Derek H. Lang, whose principal place of business is 789 Lonesome Dove Trail, Hurst, Texas, and (patient)

Who resides at:
 

and is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Patient that Physician has opted out of the Medicare program originally effective on November 4, 2004. Physician opts out every two years.
Physician agrees to provide medical services to Patient.
In exchange for the Services, the Patient agrees to make payments to the Physician pursuant to the Fee Schedule upon completion of services provided. Patient also agrees, understands and expressly acknowledges the following:

• Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
  
  
  
• Patient is not currently in an emergency or urgent health care situation.
  
  
  
• Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
  
  
  
• Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
  
  
  
• Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have opted-out.
  
  
  
• Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that the Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
  
  
  
• Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
  
  
  
• Patient acknowledges that a copy of this contract has been made available to him/her

and Dr. Lang
 

ALLERGIES: (to drugs, antibiotics, pollens and/or chemicals) Describe reaction to each.

OB-GYN History

Family History

Social History:

 Alcohol history: (type, frequency of use, number of years used)

 Illicit or intravenous drug use (type, frequency of use, number of years)

REVIEW OF SYMPTOMS

Contact Information 

 

INSTRUCTIONS FOR LEAVING MESSAGES AND/OR DISCUSSING YOUR MEDICAL CONDITION WITH OTHERS

 

As of this date:

HIPAA Privacy

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.

This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out Treatment, Payment or health care Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and became effective on April 14, 2003.

HIPAA Notice of Privacy Practices

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: