Evaluación de Riesgo para la Salud

Información Del Paciente Y Consentimiento
Información Del Paciente
Nombre*
Nombre Segundo Nombre Apellido
Fecha de Nacimiento*
Sexo*
- Masculino
- Femenino
Raza o grupo etnico*
Riesgo de salud puede variar dependiendo en grupo etnico
Estado Civil
Dirección*
Dirección Apt o Suite Ciudad Estado Código postal
Teléfono de casa*
Teléfono celular*
Empleador*
Ocupación
Años de Ocupación
Teléfono del trabajo*
Dirección de correo electrónico*
Nombre del cónyuge
Empleador del cónyuge / padres
Teléfono de trabajo del cónyuge
Doctor de Atención Primario
Por favor, enviar los registros a mi doctor de atención primario*
- Si
- No
Por favor, envíe los registros a mi médico de atención primaria*
- Si
- No
Nombre del doctor
Nombre Apellido
Teléfono de trabajo del doctor
Correo electrónico del doctor
Dirección del doctor
Dirección Apt o Suite Ciudad Estado Código postal
Información de la Aseguradora
Aseguradora primaria*
Nombre de la Compañía aseguradora*
Nombre del empleador*
Nombre del garante*
ID del miembro*
Número de grupo
Aseguradora Secundaria

Save and Continue Later

Autorización
AUTORIZACIÓN: Doy mi consentimiento y autorizo el médico tratante, el personal asociado y cualquier otro médico consultor llamado por lo anterior, para evaluar y proporcionar los primeros auxilios y prestar asistencia médica y los servicios de salud para el paciente nombrado en este formulario. Además doy mi consentimiento y autorización a los procedimientos o servicios que se consideren necesarias por dicho designado o médico de consulta.Se me ha dado ninguna garantía y se basan en ninguna en cuanto al resultado de cualquier evaluación, primeros auxilios, tratamiento o exámenes. Soy consciente de que la práctica de la medicina y la cirugía no es una ciencia exacta y reconozco que no se han dado garantías a mí como a los resultados de cualquier evaluación, primeros auxilios, diagnóstico, tratamientos médicos, quirúrgicos o terapéuticos, procedimientos, o exámenes. Por la presente autorizo a los médicos y personal que participan en el Programa de Prevención y Bienestar de SpecialtyHealt para utilizar mi información médica obtenida a través del Programa de Prevención y Binestar para porpopósito de la investigación. La investigación puede incluir casos de estudios individuales y/o compilaciones de datos del grupo/población, que pueden ser publicados y/o presentados en conferencias. Toda la información personal y médica se mantendrá confidencial. Una identificación personal será asignado a cada participante para proteger a su privacidad.
Iniciales para Autorización*
Autorizo la divulgación de cualquier información médica necesaria para procesar este reclamo. También solicito el pago de beneficios de seguro de salud a la oficina del médico, que acepta la asignación. Por la presente autorizo el pago directamente a SpecialtyHealth de los beneficios monetarios de mi plan médico. Entiendo que soy responsable por mi cuenta, independientemente de la participación de mi asefuradora. Yo entiendo que mi plan de seguro puede no cubrir servicios de nutrición u otros servicios de bienestar, y yo seré responsable por cualquier porción no cubierta por mi seguro. Por la presente autorizo SpecialtyHealth para liberar mis registros médicos para mis compañías aseguradoras. Además, autorizo pagos de beneficios médicos que se pagarán directamente a los médicos por los servicios prestados. Este acuerdo estará vigente hasta que se modifique lo contrario.
Iniciales para Asignación de Beneficios*
He recibido o se me ha proporcionado la oportunidad de recibir una copia de la "Notificación de Prácticas de Privacidad" que explica cuándo, dónde y por qué mi información confidencial de salud puede ser utilizada o compartida. Reconozco que la Clínica de SpecialtyHealth, los médicos, las enfermeras y demás personal de SpecialtyHealth puede usar y compartir mi información médica confidencial con los demás a fin de tratarme, con el fin de efectuar el pago de la factura, y por las cuestiones corciernentes a las operaciones y responsabilidades de SpecialtyHealth. También reconozco que entiendo que si tengo alguna pregunta sobre este aviso o desea presentar una queja, puede comunicarse con la Oficial de Privacidad de SpecialtyHealth por escrito. También entiendo que ningún otro miembro del personal, médico, enfermera, o cualquier otra persona está autorizado para aceptar una solicitud para ejercer mis derechos, como el Oficial de Privacidad de la Clínica de SpecialtyHealth.
Iniciales para Acuse de Recibo*
Enrollment is valid for 12 months from the date of signature
I choose the following Program Options*
- I want to sign up and participate in the Wellness & Prevention Program
- I choose not to sign up for the Program at this time
Initial Participation*
Healthy Living Options*
- I want to sign up for the Healthy Living Program
- I choose not to sign up for the Healthy Living Program but I want to receive additional information
Initial Healthy Living Program Participation*
Back on Track Program
- I want to sign up for the Back on Track Program
- I choose not to sign up for the Back on Track Program but I want to receive additional information
Initial Back on Track Program Participation

Save and Continue Later

Notice of Privacy Practices pagebreak
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION (PHI) Understanding what is in your health record and how your health information is used will help you to ensure its accuracy. It will also allow you to better understand who, what, when, and why others may access your health information and assist you in making informed decisions when authorizing disclosure of your protected health information to others. When you visit us, we keep a record of your symptoms, examination, test results, diagnosis, treatment plan, and other medical information. We also may obtain health records from other providers. In using and disclosing this protected health information (PHI), we will follow the Privacy Standards of the federal Health Insurance Portability and Accountability Act (HIPPA), 45 CFR Part 464. This law allows us to use and disclose PHI without your specific authorization for treatment, payment, and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more health care providers.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review.
- Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.
We may contact you to provide appointment reminders of information about treatment alternatives or other health-related benefits and services that may be of interest to you. All other uses and disclosures require your specific authorization. HIPAA prohibits the sale of PHI without your authorization and allows for you to opt out of fundraising communications.
Notice of Privacy Practices*
- I have read and understand the privacy practices

Save and Continue Later

Understanding Your Health Information Rights
You have the right to:
- Request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. You should address your request in writing to the Privacy Officer (see next page). We are not required to agree to a requested restriction and will notify you within 30 days in writing if we cannot agree to the restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- Obtain a paper copy of this notice and upon written request, inspect and obtain a copy of your health record for a fee of $0.60 per page and the actual cost of postage per NRS 629.061. You are not entitled to access or to obtain a copy of psychotherapy notes or information complied for legal proceedings. Copies of your records, including materials from other providers, will be provided within 30 days of receipt of your request. If payment is not made with delivery of the records, you will be billed for this service. You may also request an electronic copy of your health information held in an EHR.
- Amend your health records by submitting a written request with the reasons supporting the request to the attention of the Privacy Officer. In most cases, we will respond within 30 days. We are not required to agree to the requested amendment. If your clinician disagrees with the amendment, you will be notified in writing of the following:
  - The basis for the denial;
  - Your right to file a statement of disagreement to be kept in your file and included in future PHI disclosures;
  - Your right to complaint to the covered entity or Secretary Health and Human Services
  - Contact information for the covered entity’s privacy officer.
- Obtain an accounting of disclosures of your health information. The right to know with whom your information has been shared.
We are not required to account for disclosures for treatment, payment operations, or pursuant to authorization, among other exceptions. On request, you will be provided a report of the entities with whom your PHI was shared. Request in writing to the Privacy Officer that we communicate with you by a specific method and at a specific location. We will typically communicate with you in person; or by letter, fax, e-mail, and/or telephone. Revoke and authorization to use or disclose PHI at any time except where action has already been taken.
- You may opt to restrict disclosure of your PHI to health plans if you pay out-of-pocket in full for goods or services.
- Our health providers may share immunization records directly with schools with either written or oral consent from a parent or guardian or the individual, if the individual is an adult or emancipated minor.
Health Information Rights*
- I have read and understand my health information rights
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We have the right to change our notice of privacy practices and we will apply the change to your entire PHI. We post notice of any changes to our privacy policy in the waiting room and make a copy available to you upon request. Federal law requires that we seek your acknowledgement of receipt of this Notice of Privacy Practices, effective April 14, 2003. Please signify your acknowledgement with your signature beneath the following statement (Release of Information to Someone Designated by The Patient):
Understanding our Responsibility*
- I have read and understand

Save and Continue Later

According to the HIPAA compliance for Protected Health Information (PHI), it is necessary to provide SpecialtyHealth Clinic with name(s) of the following individual(s) with whom they may share my protected health information (PHI). It is with my informed consent that these individuals are able to speak with, be given written prescriptions and orders for procecure(s) and discuss health care; options if I am unable to do so. It is also my understanding that I may revoke this consent at any time; as long as the revocation is in writing with a signature, effective date and is received at the office of SpecialtyHealth.
Initial Release of Information*
Designated Individual(s) Authorized to receive my Personal Health Information (PHI):
Please include name and relationship to the patient
DISCLAIMER: This is not an insurance product. Many of the items may not be covered by your insurance company and therefore will be your responsibility. Healthcare professional availability for certain services may be dependent on licensure, scope of practice restrictions, or other requirements in the state. The information provided is not a substitute for your doctor’’s care and should be used as a practical guide to better health through lifestyle choices.

Save and Continue Later

Private: Health Risk Assessment

Información Del Paciente Y Consentimiento

Información Del Paciente

Doctor de Atención Primario

Información de la Aseguradora

Autorización

Historia de Salud

Para Fines de Escaneos

Revisión de Los Sistemas Del Cuerpo

Historia de La Salud Preventiva/evaluación de Riesgos

Salud Preventiva:

Consumo de tabaco

Historia Familiar

Actividad Física

Indique el tipo de actividad actual:

Dormir

Nutrición

Evaluación de la Disponibilidad

Escala de Calificación de Dolor de Espalda

Notice of Privacy Practices pagebreak

Understanding Your Health Information Rights