1 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
REGISTRATION FORM
(Please Print)
Today’s date:
PCP:
PATIENT INFORMATION
Patient’s last name:
First:
Middle:
q Mr.
q Mrs.
q Miss
q Ms.
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Is this your legal name?
If not, what is your legal name?
(Former name):
Birth date:
Age:
Sex:
q Yes
q No
/ /
q M
q F
Street address:
Social Security no.:
Home phone no.:
( )
P.O. box:
City:
State:
ZIP Code:
Occupation:
Employer:
Employer phone no.:
( )
Chose clinic because/Referred to clinic by (please check one box):
q Dr.
q Insurance Plan
q Hospital
q Family
q Friend
q Close to home/work
q Facebook
q Other
Other family members seen here:
Email Address:
Ethnicity:
q Hispanic or Latino
q Not Hispanic or Latino
q Declined
Race:
q American Indian or Alaska Native
q Asian q Native Hawaiian or Other Pacific Islander
q Black or African American q White q Declined
BILLING AND INSURANCE INFORMATION
Please give your insurance card to the receptionist.
q Check here if information is the same as patient
Name of person responsible
for bill:
Birth date:
Address (if different):
Home phone no.
/ /
( )
Is this person a patient here?
q Yes
q No
Social Security no.:
Responsible Party’s Email Address:
Occupation:
Employer:
Employer address:
Employer phone no.:
( )
Is this patient covered by
insurance?
q Yes
q No
Insurance Company:
Insurance Co. Phone #:
Subscriber ID (Policy #):
Group ID
Subscriber’s name:
Subscriber’s S.S. no.:
Birth date:
Effective Date:
Co-payment amount:
/ /
/ /
$
Patient’s relationship to subscriber:
q Self
q Spouse
q Child
q Other
Name of secondary insurance (if applicable):
Subscriber’s name:
Subscriber ID (Policy
#):
Group ID:
Patient’s relationship to subscriber:
q Self
q Spouse
q Child
q Other
2 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Work phone no.:
( )
( )
Street address:
City:
State:
Zip:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the clinic. I understand that I am
financially responsible for any balance. I also authorize VIBRANT HEALTH FAMILY CLINIC or insurance company to release any information
required to process my claims.
Patient/Guardian signature
Date
Vibrant Health Family Clinic APRN PC
All patients requesting the completion of forms must have these forms prepared and
completed during an appointment. Forms requiring extensive documentation or test results will
need to be completed and picked up after your appointment time. Your insurance company will
NOT cover the cost of this service therefore; a fee of $50 must be paid at your appointment
time. Examples of these forms are: FMLA, Short Term Disability, school, and pre-employment
evaluation forms. These forms require careful completion and review by our Provider. Please
do not ask Vibrant Health to verify medical eligibility/status without an appointment. We
appreciate your patience and understanding with this policy.
I understand the above policy.
Patient Signature ___________________________________ Date ____________________
3 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
HEALTH HISTORY QUESTIONNAIRE
Patient’s Name:
Date of Birth:
/ /
Gender:
q M q F
MEDICATIONS
List all prescriptions and over-the-counter medications, herbs and vitamins you take on a regular basis.
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
ALLERGIES
List the names of any medication, food or environmental allergies and your reactions.
Name:
Reaction:
Name:
Reaction:
Name:
Reaction:
MEDICAL HISTORY
Check the items that apply to you.
q No Medical Problems
q Abnormal pap
q Alcohol/substance
abuse
q Allergies / Hay Fever
q Asthma
q Bleeding Disorder
q Blood Clot
q Cancer
q Diabetes or
Abnormal Blood Sugar
q Headaches
q Heart Disease or
other Heart Problems
q Hepatitis or Other
Liver Problem
q High Blood Pressure
q Intestinal Problems
q Migraine
q Psychological
Problems
q Seizures
q Sexually Transmitted
Disease
q Skin Disorder
q Thyroid Disorder
q TB / Tuberculosis
q Ulcer
q Urinary Tract
Problems
q Other:
SURGICAL, HOSPITALIZATION AND TRAUMA HISTORY
Check the items that apply to you.
q None
q Appendectomy
q Back Surgery
q Brain Surgery
q Cholecystecomy
q C-Section
q Eye Surgery
q Fusion of back or
neck
q Hernia Surgery
q Heart surgery, cath or
stenting
q Hip Surgery
q Hysterectomy
q Knee Surgery
q Lung Surgery
q Surgery to wrist or hand
q Prostate Surgery
q Shoulder Surgery
q Spine Surgery
q Tonsilectomy
q Surgery to bowel, spleen or
other internal organ
q Tubal Ligation
q Vascular Surgery
q Vasectomy
q Mastectomy
q Other:
4 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
FAMILY HEALTH HISTORY
Check the items that apply to you.
FATHER’S SIDE:
q None
q Alcoholism
q Asthma
q Bleeding Disorders
q Blood cloths
q Dementia /
Alzheimer’s
q Diabetes
q Drug Addiction
q Heart Disease
q High Blood Pressure
q Psychological or
Psychiatric Problems
q Rheumatoid Arthritis
or other Autoimmune
Disease
q Stroke
q Other:
MOTHER’S SIDE:
q None
q Alcoholism
q Asthma
q Bleeding Disorders
q Blood cloths
q Dementia /
Alzheimer’s
q Diabetes
q Drug Addiction
q Heart Disease
q High Blood Pressure
q Psychological or
Psychiatric Problems
q Rheumatoid Arthritis
or other Autoimmune
Disease
q Stroke
q Other:
SOCIAL HISTORY
Complete the items that apply to you.
Marital Status: q Single q Married q Divorced q Widowed q Other:
Number of
Children:
Ages of
Children:
Highest Education Level Completed: q Current student (minor child)
q Completed 7
th
-11
th
Grade q High school Diploma q GED
q Some College q Associates Degree q Bachelor’s Degree
q Graduate Degree
Are you sexually active? q Yes q No
Birth Control Method: q Birth Control Pill q Condoms q IUD
q Depo Provera q Other:
Have you ever smoked? q Yes q No
If yes, complete/check all that apply:
q Smoke _____ cigarettes per day
q Use smokeless tobacco
q No longer smoke but smoked _____ cigarettes per day for ____ yrs
q Cigarettes/Cigar/pipe smoked inside the house
Alcohol Use:
q None
q Occasional: _____ drinks per week
q Daily: _____ drinks per day
Recreational Drug Use:
q Never used
q Used drugs in the past: ___________________________
q Use drugs currently: _____________________________
Exercise Habits:
q Never exercise
q Occasional exercise: ____ hours per week
q Regular exercise: _____ hours per week
Type of exercise:
q Running q Walking q Bicycling q Aerobics q Weight Lifting
q Yoga q Other: _______________________________
List your recent travel locations outside the United States: _________________________________________________________________
REVIEW OF SYSTEMS
Check the items that apply to you.
GENERAL SYMPTOMS: q None q Fever q Fatigue q Unusual weight change q Other:
HEAD: q None q Frequent headaches q Pain jaw with chewing q Facial pain or numbness q Other:
EYES: q None q Vision changes q Eye pain q Double vision q Other:
5 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
EARS: q None q Hearing loss q Ringing in ears q Other:
NOSE: q None q Change in smell q Postnasal drainage q Sinus problems q Other:
THROAT & MOUTH: q None q Voice Changes q Taste Disturbances q Mouth sores q Dental problems q Other:
CARDIOVASCULAR: q None q Chest pain q Palpitations q Swelling in ankles/feet q Pain in legs with walking q Other:
RESPIRATORY: q None q Wheezing q Prolonged cough q Night sweats q Coughing up blood q Abnormal chest x-ray
q Other:
GASTROINTESTINAL: q None q Difficulty swallowing q Abdominal pain q Blood in stools q Change in bowel habits
q Incontinence q Other:
GENITOURINARY: q None q Painful urination q Urgency q Frequency q Blood in urine q Prostate problems q Change in urine
stream q Impotence q Other:
MUSCULOSKELETAL: q None q Join stiffness q Joint pain q Bone deformities q Muscle pain q Back pain q Other:
SKIN/HAIR/NAILS: q None q Rashes q New or changing skin lesions q Persistent rash q Unwanted hair growth q Hair problems
q Other:
NEUROLOGIC: q None q Frequent headaches q Insomnia q Dizziness or imbalance q Numbness q Fainting q Uncontrolled
movements q Episodic vision loss q Other:
PSYCHIATRIC HISTORY: q None q Depression q Anxiety q Irritability q Recurrent bad thoughts q Hallucinations
q Other:
ENDOCRINE: q None q Intolerance to heat or cold q Changes in sex drive q Menstrual problems q Other:
BLOOD: q None q Easy bleeding or bruising q Anemia q Other:
LYMPH: q None q Unexplained swollen areas q Other:
ALLERGIC / IMMUNOLOGIC: q None q Seasonal allergies q Hay fever symptoms q Itching q Frequent Infections
q Other:
CONSENT FOR MEDICAL TREATMENT
I am the patient or the patient's duly authorized representative. I do hereby voluntarily consent to and authorize
care encompassing all diagnostic and therapeutic treatment regimens deemed necessary by my Provider, for
myself, or the patient for whom I am responsible. I am aware that the practice of medicine is not an exact
science and I do acknowledge that there have been no guarantees made to me as a result of treatment or
performed examinations. I have read this form completely, have had the opportunity to ask questions, and have
been fully informed as to the contents of this agreement. I hereby authorize the release of medical infom1ation
necessary to file a claim with my insurance company and assign benefits otherwise payable to me, to Vibrant
Health Family Clinic.
______________________________________________ ________________________
Patient/Guardian Signature Date
6 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
OFFICE / FINANCIAL POLICIES
1. Appointment Scheduling
All new patients will need to complete the new patient packet completely before being seen as a patient. Due to scheduling
constraints, we cannot guarantee same day appointments but do our best to provide work-in appointments on an as needed basis
for ill patients. Those with scheduled appointments will be seen ahead of work-ins. However, medical care can be unpredictable
and patient needs are not neglected, therefore, unseen delays may occur. PLEASE NOTE: We require a minimum of 24 hours
notification of canceling an appointment. Otherwise, a no-show will be documented on the patient's medical record. If you
are more than 10 minutes late to your visit (without a phone call letting us know), you will not be seen and it will
considered a No Show appointment.
2. Insurance
We accept most insurance plans but please ask since this can change over time. If we do not accept your insurance, payment is
due in full at each visit before you can be seen. We must obtain a copy of your driver’s license and current valid insurance card in
order to verify your insurance plan. This information will be validated at each appointment and if your insurance changes please
notify us immediately. Please contact your insurance company with any questions regarding covered or non-covered procedures,
tests, labs, medications or any other medically necessary recommendations. Co-Pays are required to be paid PRIOR to being
seen for your visit. If your insurance company does not pay your claim entirely, it is your responsibility to make payment.
3. Cash Payments
We accept patients on a cash basis. All payments must be made prior to being seen. We accept payment in cash or credit card.
• New Patient Visits: $140
• Patient Visit: $90
• Well Child Visit: $80
• Sports Physicals: $50
• Lab Draw Fee: $25
• Lab Fees: Varies depending on the laboratory
procedure
4. Canceling Appointments / No Shows
If you cannot attend your appointment, we require a 24-hour notice so that the appointment can be made available for one of our
patients. Please call the office as soon as you know you will not be able to make it. Appointments not cancelled 24 hours in
advance will be considered a “No Show” appointment. If a patient accumulates 2 No Show appointments, the patient will only
be allowed to make SAME DAY appointments and can also result in dismissal from our clinic.
5. Medication Refills
All medication refills require a follow-up visit within 1 - 3 months with accompanying lab work. This includes routine prescriptions for
chronic medications. All medications have the potential to affect your liver, kidneys, and other body systems. Routine follow-up with
lab work allows our Provider to monitor your progress. Please bring all bottles prescribed by all of your Providers with you to your
appointments. This decreases the chance of duplicate refills and dangerous drug interactions. We will NOT HONOR PHONE
CALL REQUESTS FOR MEDICATION REFILLS. All controlled medications require an in-office urine drug screen and pill count to
be performed during the refill visit.
6. Medical Records
All of our patient medical records are kept confidential. By law, we are required to keep the original medical record in our
possession for 7 years. Copies may be furnished to you when you request them in writing. Our policy requires 7-day notice for the
preparation of copies. Charges are in accordance with the state law Chapter 64B8-10.003 that states the following: “Reasonable
costs may not be more than $1 per page for the first 25 pages and $0.25 for every page thereafter.” Copies are provided for free to
the provider of your choice upon transfer from the practice and also to a specialist for continuity of care.
7. Referral Orders
As a Primary Care Provider, we offer referrals to specialists. These referrals take a lot of time and attention from our staff to prepare
and track. If you do not keep your appointment for your referrals that were prepared by our office, we will limit future referral orders
to 1 per visit.
8. Pain Management
Chronic pain management is NOT provided at Vibrant Health Family Clinic. In certain cases where a patient is awaiting work-
up of a surgical problem or acceptance to pain management, prescriptions may be given for 1-2 months. There are NO
REPLACEMENT PRESCRIPTIONS GIVEN WITHOUT A POLICE REPORT. Dismissal from a pain medication clinic could result in
dismissal from this clinic and/or the cessation of controlled prescription medication. No further referrals for pain management will be
made.
9. Controlled Substances
• Controlled medications will only be refilled monthly with an appointment.
• All schedule 3 and 4 medications will be written for only 1 month at a time. Every month, patients will need to be seen IN THE
OFFICE. This includes, but is not limited to, the following: All forms of pain medications, most muscle relaxers, most sleeping
agents (Ambien, Zolpidem, Lunesta), all benzodiazepines (Klonopin/Clonazepam, Restoril/Temazepam, Serax/Oxazepam,
Zanax/Alprazolam), Codeine Preparations (Tylenol #3, Tussionex), Testosterone Replacements (Testim, Androgel, Fortesta,
Axiron, Cypionate, Enanthate).
• Patients may be tested at every appointment and any inconsistent findings could result as a patient from this clinic.
• We do not prescribe any stimulant medications (such as Concerta, Ritalin, Adderall, Dextroamphetamine, Vyvanse) for adults or
children diagnosed with ADD/ADHD. We will recommend that you return to the psychiatrist that originally made that diagnoses. If
that is not possible, we will gladly provide you with recommendations for local psychiatrists to assist with this. Non-controlled
medications (such as Strattera) may be managed at this office.
• Obtaining a controlled medication from any other provider, with the exception of a referring provider, could result in a dismissal
from this clinic.
______________________________________________ ________________________
PATIENT NAME PATIENT’S DATE OF BIRTH
_____________________________________________ _______________________
PATIENT / GUARDIAN SIGNATURE TODAY’S DATE
7 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
Ken Warren, APRN
1822 E 15
th
Street, Suite A, Tulsa, OK 74104
PH: (918) 591-3567 | FAX: (918) 591-3568
MEDICAL HOME AGREEMENT
This Medical Home Agreement Concept is an agreement between you and your provider to meet all of your healthcare needs.
As your Medical Home Primary Care Provider (PCP), we agree to:
1. Respect your rights as a patient. Treat you with dignity.
2. Focus on listening to your concerns. Educate you on your health care. Provide and track preventive services.
3. Focus on treating you as a whole person: physically, mentally and emotionally.
4. Focus on providing you with quality and safe health care.
5. Work to schedule office appointments in a timely manner.
6. Be available to you 24 hours a day, by appointment, phone calls and/or electronic communication.
7. Provide you with other healthcare resources when we are unavailable.
8. Provide you with referrals to specialist it determined medically necessary.
9. Provide you with treatment, medications, equipment and any other resources if determined medically necessary.
As a Medical Home Patient, your responsibility is the following:
1. Work with us, as your PCP, to meet a// of your health care needs.
2. Communicate with us about all your healthcare concerns and goals.
3. Report any changes related to your health, treatments, medications, etc. This includes use of all medications, prescribed, over-the
counter, herbal and/or street drugs. This also includes any medical equipment being used, ordered or recommended.
4. Call us before going to the Emergency Room, unless it is life threatening.
5. Notify us after any Emergency Room, Urgent Care Clinic or Hospital visit.
6. Schedule all medical appointments in a timely manner.
7. Keep appointments as scheduled with us and any specialists.
8. If you cannot keep an appointment call before your appointment time to cancel or reschedule.
9. You may be dismissed from your PCP panel if you repeatedly miss appointments without notice.
YOUR HEALTHCARE IS A TEAM APPROACH INVOLVING BOTH YOU AND YOUR PROVIDER!
________________________________________________ ________________________
Patient/Guardian Signature Date
________________________________________________ ________________________
Healthcare Provider Date
8 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
Ken Warren, APRN
1822 E 15
th
Street, Suite A, Tulsa, OK 74104
PH: (918) 591-3567 | FAX: (918) 591-3568
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
PATIENT’S NAME:
Date of Birth:
Previous Name:
Social Security #:
I request and authorize _________________________________________ to release healthcare information of the patient named above to
VIBRANT HEALTH FAMILY CLINIC, APRN, PC at 1822 East 15
th
Street, Ste 1, Tulsa, OK 74104 at Phone Number (918) 591-3567 and
Fax Number (918) 591-3568.
The request and authorization applies to:
q Healthcare information relating to the following treatment, condition or dates:
q All healthcare information
q Other:
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma
virus, wart, genital wart, condyloma, Chlamydia, non -specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV
(Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
q Yes q No
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to
the person(s) listed above. I understand that the person(s) listed above will be notified that I
must give specific written permission before disclosure of these test results to anyone.
q Yes q No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to
the person(s) listed above.
THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED.
_________________________________________ ________________________
Patient/Guardian Signature Date
9 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
Ken Warren, APRN
1822 E 15
th
Street, Suite A, Tulsa, OK 74104
PH: (918) 591-3567 | FAX: (918) 591-3568
AUTHORIZATION
PATIENT’S NAME:
Date of Birth:
Patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file your insurance, however you are
responsible for your co-pay and/or percentage, which the insurance company is not liable for on the day of your visit. In the event your
insurance company has not paid within 60 days you are responsible for the balance due. It is also the patient's responsibility to obtain
referrals from your primary care physicians when required. If the referral is not obtained before the visit, the patient is liable for payment in
full on the date of service. If we are unable to obtain payment within a reasonable amount of time from the patient and/or guarantor we will
place your account with a collection agency, which will leave you liable for additional expenses incurred if applicable.
I ____________________________________ have fully read and understand the above statement of payment policy. I hereby request any
benefits on my behalf, to be paid to the health care providers. I also authorize the release of any information acquired in the course of my
treatment to my insurance company as needed to issue benefits. I authorize the healthcare providers to administer such treatment as they
may deem advisable for my diagnosis and treatment. I certify that I have been made aware of the role and services offered by the physician,
physician assistant and nurse practitioner and I consent to cart by such providers. I understand that these services are voluntary and that I
have the right to refuse these services.
_________________________________________ ________________________
Patient/Guardian Signature Date
I authorize this facility to release information to (Please check all that apply):
q Spouse: List complete name of spouse _______________________________________________________________
q Children: List complete names/phone # of children _______________________________________________________
q Other: List complete names/phone # _________________________________________________________________
_________________________________________ ________________________
Patient/Guardian Signature Date
MEDICARE PATIENTS
I request that payment of authorized Medicare (Medicare Supplement) benefits be made on my behalf to the provider for any services
furnished me by the provider. I authorize any holder of medical information about me: to release Medigap Insurer
___________________________________ any information needed to determine those benefits payable for related services.
_________________________________________ ________________________
Patient/Guardian Signature Date
MEDICARE LIFETIME AUTHORIZATION
I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct and authorize, any
holder of the medical information about me to release to the Social Security Administration or its intermediaries or carriers any information
needed for this or a related Medicare claim. I request that the payment or authorized benefits be made on my behalf. I assign the benefits
payable for healthcare provider services to the healthcare provider or organization furnishing the services or authorized such nurse
practitioner or organization to submit a claim to Medicare for payment to me. I request that this authorization also apply to all other
insurances.
_________________________________________ ________________________
Patient/Guardian Signature Date
_________________________________________ ________________________
Print Name Title or Relationship
_________________________________________ ________________________
Witnessed by Address
10 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY VIBRANT HEALTH
FAMILY CLINIC 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 condition and related health care services.
HOW WE MAY USE OR DISCLOSE YOUR 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
REQUIRED USES AND DISCLOSURES
By law, we must disclose your health information to you unless it has been determined by a competent medical authority that it would be
harmful to you.
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, 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.
HEALTH CARE OPERATIONS AND OVERSIGHT
We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s/nurse
practitioner’s practice. These activities include, but are not limited to, quality assessment, employee review, 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 healthcare provider 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, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
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 as required by law, communicable diseases, health oversight, abuse or neglect, food and drug
administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity,
military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must
make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the
Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section
164.500. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if
the information is necessary for such functions or services. For example, we may use another company to perform billing services on our
behalf. All of our business associates are obligated to protect the privacy of your information and abide by the same HIPAA Privacy
standards as outlined in this Notice of Privacy Practice.
Other Permitted Uses and Disclosures Requiring Your Written Authorization
Unless noted above in our Use and Disclosures, all other permitted uses and disclosures of your protected health information will be made
only with your consent, authorization or opportunity to object unless required by law. This includes:
• Most uses and disclosure of psychotherapy notes Updated 01.28.15 / asw
• Uses and disclosure for marketing purposes
• Disclosures that constitute a sale of your protected health information.
You may revoke the 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
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not
inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or
administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which
you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was
obtained under a promise of confidentiality. If your Protected Health Information is maintained in an electronic format (known as an electronic
medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or
transmitted to another individual or entity. If the Protected Health Information is not readily producible in the form or format you request your
record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We have
up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying,
mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits
under the Social Security Act or any other state of federal needs-based benefit program.
11 | VIBRANT HEALTH FAMILY CLINIC Updated January 2018
NOTICE OF PRIVACY PRACTICES
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 and by law we must comply when the protected health information pertains solely to a health
care item or service for which the health care provider involved has been paid out of pocket in full. 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. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.
You have the right to request to receive confidential communications – You have the right to request confidential communication 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 have the right to request an amendment to 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 – You have the right to receive an accounting of all disclosures
except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that
occurred prior to April 14, 2003, or six years prior to the date of this request. You have the right to receive a Breach Notification. You have
the right to receive a notification upon a breach of any of your unsecured Protected Health Information. You have the right to obtain a paper
copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this
notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish
to obtain one.
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 Compliance Officer of your complaint. We will not retaliate against you for filing a complaint. 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. We are also required to abide by the terms of the notice currently in effect. If you have any questions in
reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number (918) 591-
3567. Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are only
acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices
ACKNOWLEDGMENT OF RECEIPT
OF NOTICE OF PRIVACY RIGHTS
By signing below, I hereby acknowledge receipt, on this date, of the Notice of Privacy Rights, under the provisions of the Health
Insurance Portability and Accountability Act: (“HIPAA”). Vibrant Health Family Clinic has provided this document to me.
I have been advised that except for evaluation and treatment, payment matters and clinic operations, under HIPAA, protected
health information will not be disclosed without my written authorization.
_________________________________________ ______________________________________
Patient/Guardian Signature Date
_________________________________________ ______________________________________
Print Name Patient’s Name (if different than signature)
