Patient Intake Form

I hereby give lifetime authorization for payment of insurance benefits to be made directly to ENDOCRINE PARTNERS and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

By signing below, you consent to use and disclosure of your Protected Health Information (PHI) by Lorena Lewy-Alterbaum, M.D., F.A.C.E and/or our staff, and our business associates for treatment, payment, and health care operations. For more detailed descriptions of uses and disclosures for these purposes, please review our “Notice of Privacy Practice.” This Notice of Privacy describes your rights and the doctor’s duties with respect to your Protected Health Information. You have the right to review our Notice prior to signing this consent. The terms of this Notice may change. If the terms change, you may receive a revised Notice by simply calling the office and requesting a revised copy be sent in the mail or by asking for one at time of your next appointment. You have the right to request that we restrict our uses or disclosures of your protected health information that we are otherwise permitted to make for diagnosis, treatment, payment and health care operations, although we are not required to agree to these restrictions. However, if we disagree to these restrictions, they are binding on us. Finally, you may refuse to consent to the use of our disclosure of your Protected Health Information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Protected Health Information. “Protected Health Information” means health information including demographic information, collected from you, the patient and received by your physician, another health care provider, health plan, employer or health care clearinghouse. This Protected Health Information relates to your past, present, or future physical or mental health conditions.

I HAVE REVIEWED, UNDERSTAND AND AGREE TO THE CONTENT OF THE NOTICE OF PRIVACY. I CONSENT TO THE USE OR DISCLOSURE OF ANY PROTECTED HEALTH INFORMATION BY DR. LORENA LEWYALTERBAUM AND/OR STAFF FOR THE PURPOSE OF THE DIAGNOSIS, TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. I UNDERSTAND THAT MY DIAGNOSIS AND TREATMENT MAY BE CONDITIONED UPON MY CONSENT AS EVIDENCED BY MY SIGNATURE ON THIS DOCUMENT. THIS FORM IS ALSO USED TO OBTAIN ACKNOWLEDGEMENT OF RECIEPT OF OUR “NOTICE OF PRIVACY” OR TO DOCUMENT OUR GOOD FAITH EFFORT TO OBTAIN THAT ACKNOLEDGEMENT.

ADVANCE DIRECTIVE

NOTICE OF PRIVACY PRACTICES

SUMMARY:
By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notices describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:

1. The right to inspect and copy your information.

2. The right to request corrections to your information.

3. The right to request that your information is restricted.

4. The right to request confidential communications.

5. The right to a report of disclosures of your information.

6. The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.

If you have any questions about this Notice, please contact our office manager.

Contact Person: Milly A.

Phone Number: (954) 967-0500

I hereby acknowledge that I have received a copy of this practice’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints, regarding my privacy rights, that I may contact the person listed above. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.

Detailed Medical Information

Family History