Welcome to University of Louisville Physicians Geriatrics Practice! We will partner with you to
provide excellent care.
Our practice is striving to provide patient-centered care. This will incorporate team based,
comprehensive, coordinated care in order to deliver the best possible healthcare services for you.
Your healthcare team is made up of your choice of a Primary Care clinician and a team of support
staff to work with you to meet all of your healthcare needs. Our electronic healthcare tools (along
with other resources) will assist us in providing the best medical care, tailored specifically for
you.
Our doctors will need to know more about you if we are going to be your health partner and so we
ask that you please completely fill out each form that we have enclosed in this packet. Again,
please read ever yt h i n g carefully, complete the necessary information and sign your name
wherever it is required
on all of the enclosed
forms
.
Please return all of your completed paperwork in the enclosed envelope to:
UofL Physicians - Geriatrics
401 E. Chestnut Street, Suite 170
Louisville, KY 40202
On every visit, please remember to bring in A LL o f your current
insurance
cards, photo
identification, your co-payment (if you have one) and all
medication (including supplements)
y
ou
take in their original bottles with you
.
Please arrive 15 minutes ahead of your scheduled
appointment time so that if you have questions about the forms or in the event we should need
more information, we can address it all prior to your appointment.
You can contact your team member anytime during our normal office hours (Monday through
Friday 8:00 a.m. – 5:00 p.m., EST, except for holidays) by calling the practice location of your
healthcare team, listed at the bottom of this page. Outside of normal office hours, please use the
same phone number and the answering service will be able to take your message and have on-call
personnel return your call. Please continue to call 911 for all emergencies. We have
implemented our PATIENT PORTAL which allows you to learn about a particular medical
condition, electronically communicate with your healthcare team, review your medical records
and even receive reminders about your personal conditions. Please ask our front desk personnel
how you can register for your patient portal.
We realize that you have many choices and we thank you for choosing to partner with us. We
look forward to seeing you!
University of Louisville Physicians Geriatrics
UofL Physicians Family & Geriatric Medicine
UofL Physicians Family Medicine UofL Physicians Family Medicine UofL Physicians Geriatrics at UofL Physicians Center for Primary Care at Sports Medicine
Cardinal Station Newburg UofL Health Care Outpatient Ctr Cardinal Station Cardinal Station
p 502.588.8720 p 502.588.2500 p 502.588.4271 p 502.588.8700 p 502.637.9313
PATIENT REGISTRATION INFORMATION
NAME LAST
FIRST
MI
BIRTHDATE
AGE
SEX
SOCIAL SECURITY # HOME PHONE CELL PHONE IF MARRIED,SPOUSE NAME
ADDRESS
STATE ZIP
IF PATIENT IS A CHILD, NAME OF MOTHER LAST
FIRST
MI
CHILD LIVES WITH:
IF PATIENT IS A CHILD, NAME OF FATHER LAST
FIRST
MI
IN CASE OF AN EMERGENCY, CONTACT (SOMEONE IN ANOTHER HOUSEHOLD, i.e., GRANDPARENT, FRIEND, ETC.)
HOME PHONE
WORK PHONE
ADDRESS
CITY
STATE ZIP
RACE/ETHNICITY
RELIGION
LANGUAGE
DO YOU HAVE A LIVING WILL OR OTHER FORM OF ADVANCE DIRECTIVE?
NAME OF PRIMARY CARE GIVER PRIMARY CARE GIVER PHONE #
PRIMARY INSURANCE INFORMATION
PERSON RESPONSIBLE FOR THE ACCOUNT
EMPLOYER
WORK PHONE
ADDRESS (IF DIFFERENT FROM PATIENT)
CITY
STATE
ZIP
HOME PHONE
NAME OF INSURANCE COMPANY
SUBSCRIBER’S NAME LAST
FIRST
MI
SUBSCRIBER’S SOCIAL SECURITY #
SUBSCRIBER’S BIRTH DATE
PATIENT’S RELATIONSHIP TO SUBSCRIBER
POLICY # OR ID #
GROUP #
EFFECTIVE DATE
ADDRESS
CITY
STATE
ZIP
SECONDARY INSURANCE INFORMATION
NAME OF INSURANCE COMPANY SUBSCRIBER’S NAME LAST FIRST
MI
SUBSCRIBER’S SOCIAL SECURITY #
SUBSCRIBER’S BIRTH DATE
PATIENT’S RELATIONSHIP TO SUBSCRIBER
INJURY RELATED INFORMATION
DATE OF INJURY
(MONTH/DATE/YEAR)
WORK RELATED
AUTO
MOTORCYCLE
OTHER
Do you or your spouse or any family member work for a
company that provides you with health insurance?
YES
NO
CLAIM #
CONTACT NAME
CONTACT PHONE
Do you have a Medical Card or a State Card?
YES
NO
Have you applied for disability?
YES
NO
INSURANCE COMPANY
Is this visit the result of an Auto Accident?
YES
NO
INSURANCE COMPANY ADDRESS
Is this visit the result of a Work-Related Accident?
YES
NO
CITY
STATE
ZIP
Are you presently covered under any other insurance?
YES
NO
Date: ________________________________ Patient Signature: __________________________________________________
I:\FCM\Phyllis Harris\Forms\New Patient Pkg Components\Pt Registration Form
pdh/07.11.13
__________________________________________________________________________________________________
Name ______________________________________________________________________ Date of Birth: ____________________
WELCOME to UofL Physicians Family & Geriatric Medicine
FAMILY HISTORY
Father: Present Health/Cause of Death
Mother: Present Health/Cause of Death
Spouse: Present Health/Cause of Death
Total # Brothers
# Alive
Health
# Deceased
Cause(s) of Death
Total # Sisters
# Alive
Health
# Deceased
Cause(s) of Death
Total # Children
# Alive
Ages & Health
# Deceased
Ages & Cause(s) of Death
Circle Illnesses which have occurred in your parents, aunts, uncles, grandparents and/or children:
Diabetes Stroke Heart Disease Tuberculosis Bleeding Tendency Kidney Disease Emphysema
High Blood Pressure Mental Illness Cancer: _______________________________ (Please list type)
MEDICAL HISTORY
Check Symptoms you currently have or have had recently within the past 6 months:
General
Gastrointestinal
Eye / Ear / Nose / Throat
Men ONLY
□
Chills
□
Poor Appetite
□
Double Vision
□
Erection Difficulties
□
Fever
□
Stomach Pain
□
Blurred Vision
□
Lump in Testicle
□
Night Sweats
□
Bloating
□
Vision Flashes / Halos
□
Penis Discharge
□
Fatigue
□
Vomiting
□
Dry Eyes
□
Sore on Penis
□
Forgetfulness
□
Vomiting Blood
□
Itchy Eyes
□
Other _____________________
□
Sleep Issues
□
Nausea
□
Earache / Ear Discharge
□
□
Weight Loss
□
Indigestion / Heartburn
□
Loss of Hearing
Women ONLY
□
Weight Gain
□
Bowel Changes
□
Ringing in Ears
□
Abnormal Pap Smear
□
Excess Thirst
□
Constipation
□
Sinus Problems
□
Bleeding between Periods
Muscular / Bone / Joints
□
Diarrhea
□
Nosebleeds
□
Extreme Menstrual Pain
□
Leg Cramps
□
Excess Gas
□
Hayfever / Allergies
□
Painful Intercourse
□
Back Pain
□
Hemorrhoids
□
Hoarseness
□
Vaginal Discharge
□
Muscle Pain
□
Blood in Stool
□
Sore Throat
□
Nipple Discharge
□
Joint Pain
Cardiovascular
□
Difficulty Swallowing
□
Breast Lump
□
Joint Swelling
□
Bleeding Gums
□
Hot Flashes
□
Other:
□
Chest Pain
Skin & Nails
□
Date of Last Menstrual Period
□
High / Low Blood Pressure
Urinary
□
Irregular / Rapid Heart Rate
□
Easy Bruising
□
Date of Last Pap Smear
□
Blood in Urine
□
Poor Circulation
□
Easy Bleeding
□
Date of Last Mammogram
□
Frequent Urination
□
Swelling of Lower Legs
□
Rash
□
Are you Pregnant? Yes No
□
Lack of Bladder Control
□
Varicose Veins
□
Hives
□
Number of pregnancies
□
Painful Urination
□
Calf Pain with Walking
□
Abnormal Scarring / Keloids
□
Pulmonary
Neuro
□
Sores that Won’t Heal
Mental Health
□
Cough
□
Headache
□
Change in Moles
□
Depression
□
Coughing up Blood
□
Dizziness
□
Acne
□
Anxiety
□
Shortness of Breath
□
Fainting
□
In-Grown Toe Nails
□
Thoughts of hurting yourself
□
Shortness of Breath w/Exertion
□
Seizures
□
Fungal Infections
□
Thoughts of Suicide
□
Snoring
□
Numbness
□
□
Alcohol Abuse
□
Wheezing
□
Tingling
□
□
Substance Abuse
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Name _____________________________________________________________
(continued) Date of Birth: ____________________
PLEASE LIST ALL medications, supplements / vitamins and over-the-counter-medications you are currently taking:
PLEASE LIST ALL allergies to medications, food and/or latex:
Please check conditions you have had in the past:
□
AIDS
□
Lupus
□
HIV Positive
□
Polio
□
Appendicitis
□
Diabetes ____Type 1 ____Type 2
□
Kidney Disease
□
Prostate Problem
□
Arthritis
□
Emphysema / COPD
□
Liver Disease
□
Rheumatic Fever
□
Asthma
□
Epilepsy / Seizures
□
Chicken Pox or Shingles
□
Scarlet Fever
□
Bleeding Disorders
□
Glaucoma or Cataracts
□
Migraine Headaches
□
Stroke
□
Breast Lump
□
Heart Disease
□
Multiple Sclerosis
□
Thyroid Problems
□
Cancer
□
Hepatitis A / B / C (circle one)
□
Skin Cancer
□
Tuberculosis
□
Raynaud’s Disease
□
Herpes
□
Pacemaker
□
Ulcers
□
Alcohol or Drug Abuse
□
Bipolar
□
Pneumonia
□
Reflux
□
High Blood Pressure
□
Depression / Anxiety
□
High Cholesterol
□
Sexually Transmitted Diseases
HOSPITALIZATIONS / SURGERIES / FRACTURES
Year
Diagnosis / Issue
Health Habits
Dates for last: Tetanus Shot _____________ Pneumonia Vax ______________Shingles Vax _______________Flu Vax ____________
Tobacco Use: Yes No
Alcohol Use: Yes No
Caffeine Use: Yes No
Exercise: Yes No
How much? _________
per day/ week / month How many drinks? ______ How many drinks? ______ How many times? ______
**Desire to Quit?** per day/ week / month
per day/ week / month per day/ week / month
Yes
No
Maybe
Signatures
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any staff member responsible
for any errors or omissions that I may have made in the completion of this form.
Signature:_______________________________________________________________ Date: ___________________
Reviewed by: ____________________________________________________________ Date: ___________________
___________________________________________________________________ _________________________
GENERAL CONSENT FORM
PATIENT NAME: __________________________________________ Date of Birth: _____________________
Payment. I authorize University of Louisville Physicians, Inc. (UofL Physicians) to submit claims on my behalf directly to
Medicare/Medicaid/my private health insurance carrier. This means that UofL Physicians will direct payment for supplies
and services provided. I understand that I am financially responsible to the pr ovider(s) for the charges not paid or payable. I
authorize you to release any information necessary to insurance carriers regarding illnesses and treatment to process
claims. Patient Initials: ______________
Consent for Treatment. I consent for UofL Physicians to administer treatments, tests and/or diagnostic tests to treat my/the
patient’s injury/illness on an outpatient basis. I acknowledge there is no guarantee as to the outcome of any treatment I/the
patient receives. In compliance with state law, as part of the care to be given a test may be performed for human
immunodeficiency virus infection (HIV/AIDS), hepatitis, or other blood-borne infectious or communicable diseases if the
doctor, APRN, or Physician Assistant orders the test for diagnostic purposes because of my/the patient’s medical history,
symptoms, or conditions. Patient Initials: ______________
Electronic Prescription. I understand UofL Physicians utilizes electronic prescribing technology and participates with
SureScripts. SureScripts operates the Pharmacy Health Information Exchange, which facilitates the electronic transmission
of prescription information between providers and pharmacists. SureScripts also provides prescription data on any
medications, known as medication history, which are prescribed to me/the patient. Patient Initials: _______________
Cell Phone Calls. As a service to our patients, we provide a courtesy appointment reminder call and possibly other
important calls that may be placed using a prerecorded message. By providing your cell phone number, you consent to
receiving such calls at this number.
Involvement of Others in Care. I authorize UofL Physicians to provide and discuss my/the patient’s care and medical
needs with the following persons:
Name
Relationship
Phone
Patient Rights and Responsibilities
I acknowledge receipt of the Patient Rights and Responsibilities_____ Declined_____
Notice of Privacy Practices
I acknowledge receipt of the Notice of Privacy Practices_____ Declined_____
Minor Patient Photograph
I consent for UofL Physicians to photograph the patient for identification purposes only_____ Declined_____
Patient/Parent/Legal Guardian/Legal Authorized Representative Signature Date
If Parent/Legal Guardian/Legal Authorized Representative, Print Name _________________________________________
REG-03
Revised October 10, 2013
of Louisville Physicians
|
Cardinal Station • Newburg • Centers for Primary Care • Sports Medicine • Geriatrics
Office
Acknowledgements and Policies
1. I am aware of the policy regarding diagnostic tests. UofL Family and Geriatric Medicine will attempt to
inform me of the results within 14 days. If I have not received a call or notification by mail in 14 days,
it is my responsibility to contact the office. I WILL NOT assume that results are normal if I have not
heard from the office.
2. If I need to cancel or reschedule an appointment I will do so 24 hours in advance.
3. Please arrive 15 minutes early to your appointment. If I arrive late, I may be asked to reschedule or
wait until scheduled patients have been seen.
4. I understand that all co-payments and account balances are due at the time of service.
5. I understand that I will be charged $25 for any returned checks.
6. I am aware that medications will be filled only during regular office hours (Monday-Friday, 8:30am-
5:00pm). Please allow 48-72 hours for refills to be processed.
7. I will notify the receptionist if my appointment involves care for a motor vehicle accident or a work-
related injury.
8. I agree to turn off or silence my cell phone while in the office.
9. I will bring all of my medication in its original bottle to every visit.
10. I understand that no pain medication will be filled on the first visit. Medical records must be
received and reviewed before consideration of prescription refills.
11. I understand that there will be a $10 charge for any forms completed by the providers. (FMLA,
disability, etc.)
12. I understand that I must reapply for the Sliding Fee Scale/Gold Card every 90 days. I also understand
that if I am a Pay Class 6 there will be a $20 charge for office visits and a 20% charge for all other
services. If I am classified as another Pay Class, I will pay a percentage for the office visit and all other
services performed up to 100%. (Does not apply to Centers for Primary Care patients.)
By signing below, I acknowledge that I have been informed of these policies.
/ /
Patient or Guardian Signature Patient Date of Birth Today’s Date
I, the undersigned, certify that I (or my dependent) have the insurance coverage on record at UL Family Medicine and assign these benefits directly to UL Family
Medicine. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the release of and the use of my signature
on all insurance submissions. In Medicare assigned cases, the physician agrees to accept the charge determination of the carrier as full charge, and the patient is
responsible for the deductible, coinsurance, and non-covered services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.
PRINT Name of Patient Signature of Patient, Parent, or Guardian Relationship to Patient Date
I:\FCM\Phyllis Harris\Forms\Office Acknowledgement
Revised 03.04.13/pdh
______________________________________ __________________ _________________
______________________________________ _______________________________ ____________
______________________________________ __________________ _________________
______________________________________ _______________________________ ____________
GENERAL REQUEST FOR RELEASE OF MEDICAL RECORDS
To be used for release of information to the patient, their legal representative, or to a provider of
their choice; or to authorize the request of records from another provider.
In order to release your/the patient’s records, you must sign a request for release. This form must be
complete with the patient’s name, the last 4 digits of the patient’s social security number, and the patient’s
date of birth. It is your responsibility to read this form in full and to ask any questions before the record is
released. No phone call request will be honored.
Release of Records by University of Louisville Physicians, Inc. (UofL Physicians)
The following information explains our policy for releasing protected health information:
Medical records will be released only to the patient or the patient’s authorized representative. Law
office/attorney medical records requests must have valid authorization with request.
You must show ID to receive records. This is for the protection of your personal health information.
Patient’s legal representatives must provide appropriate documentation to demonstrate their legal status.
HIV, STD, and mental illness notes are not released without authorization.
Please allow up to 30 days for records stored off site; however, University of Louisville Physicians may take
up to 60 days to process the request, if necessary.
First copy provided free of charge.
Patient’s Name (Please Print) Date of Birth Last 4 Digits of SSN
Patient/Parent/Legal Guardian Signature Witness Signature Date
If Parent/Legal Guardian, Print Name ________________________________________
List Records Being Requested ___________________________________________________________
Medical Record Release to Patient/Legal Representative
Release to Provider Office
Provider Name _______________________________________ Phone __________________________
Provider Address _____________________________________________________________________
Street City State Zip
UofL Physicians Request Records from Another Provider
Patient’s Name (Please Print) Date of Birth Last 4 Digits of SSN
Patient/Parent/Legal Guardian Signature Witness Signature Date
If Parent/Legal Guardian, Print Name _________________________________________
List Records Being Requested ___________________________________________________________
Other Provider Name __________________________________ Phone __________________________
Other Provider Address ________________________________________________________________
Street City State Zip
UofL Physicians Practice Site (optional) ___________________________________________________
COMP-01
Revised October 9, 2013
This page
intentionally
left blank.
University of Louisville
Physicians
UofL Health Care Outpatient
Center
401 East Chestnut Street
Louisville, KY 40202
JOINT NOTICE OF PRIVACY
PRACTICES
University of Louisville Physicians
Organized Health Care Arrangement
Effective Date: April 14, 2003
Revised: December 1, 2013
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.
OUR PLEDGE TO YOU
Your health information is something that University
of Louisville Physicians has always worked to keep
private. We also are ethically and legally bound to
keep it confidential under state and federal laws.
WHAT IS THIS DOCUMENT?
This document, called a Joint Notice of Privacy
Practices, tells you how we may use and share your
health information. This includes using and sharing
it so that we may provide you with health care and
be paid for it, and so that we may run our business
and follow state and federal legal rules. We are
required by law to provide you with this notice and
to follow its terms.
WHO FOLLOWS THIS NOTICE
This Joint Notice describes the privacy practices of
the following groups or entities:
1) University of Louisville Physicians practices
2) University of Louisville Practices: Children
and Youth Project, Neonatal Follow-up,
Weisskopf Child Evaluation Center
(WCEC), Pediatrics Kosair Charities clinic,
550 Clinic and Campus Health Services (all
locations)
Other separate health-care providers at the
University of Louisville Medical Center also may
provide you with health services. You might receive
a notice of privacy practices from them, too.
WAYS WE MAY USE AND SHARE YOUR
HEALTH INFORMATION FOR CERTAIN
PURPOSES WITHOUT YOUR PERMISSION.
Treatment. We will use and share your medical
information for your care.
Example: Doctors, dentists, students, medical
residents or other university workers may read your
record to learn if a treatment is working. Your
medical information also may be shared with
doctors or dentists outside of University of Louisville
Physicians to decide the best treatment for you.
Payment. We may use and share your
medical information to be paid for the care and
services we provided you.
Examples: We may contact your insurance
company to check coverage or benefits for a certain
procedure, or for referral purposes. Please be
aware that we report information to insurance
companies based on the insurance information you
provide. Insurance companies send bills to the
person who is named on the insurance card, which
may or may not be you.
Healthcare Operations. We need to use and share
your health information to run our health-care
business. We may use or share your information for
several reasons related to our health care activities.
Examples: We may share your medical information
in our training programs where students, trainees,
or other health care practitioners learn to improve
their health care skills. Your information may also
be used for quality improvement, safety programs,
and to see how well our healthcare personnel are
doing.
HIP-33F
Revised November 25, 2013 will make effective 12/1/13
University of Louisville
Physicians
UofL Health Care Outpatient
Center
401 East Chestnut Street
Louisville, KY 40202
Business Associates. We may share your medical
information with another company or organization,
called a “business associate” that we hire to provide
a service to us or on our behalf. Business
Associates must also follow privacy rules.
Example: A company that submits bills on our
behalf to your insurance company.
Appointment Reminders. We may contact you to
remind you of an appointment or to change one.
We may also let you know that it is time for a follow-
up appointment or a regular check-up.
Health-Related Benefits, Services and
Treatment Alternatives. We may contact you to let
you know about health-related benefits or services,
or possible treatments alternatives that may be of
interest to you.
Fundraising Activities. UofL health care providers
rely on the kindness of the community to help us
provide quality health care to this region. Patients
who share their experiences and suggest ways to
work with us are giving back in a meaningful way.
Their information also helps us improve and expand
our services. We may use limited information about
you, called demographic information, along with the
dates you received care, the department and/or
physician who provided your care, outcome
information, and your health insurance status for
fundraising efforts to support our mission. We also
may share this information with our related
foundation or business associates so they can
contact you for your support. Your generosity helps
us continue to be an outstanding provider of health-
care services in this region. You have a right to opt
out of receiving such communications.
Required Disclosures. The Secretary of the
Department of Health and Human Services may
investigate privacy violations. If your health
information is requested as part of an investigation,
we must share your information with the Secretary
JOINT NOTICE OF PRIVACY
PRACTICES
University of Louisville Physicians
Organized Health Care Arrangement
Effective Date: April 14, 2003
Revised: December 1, 2013
of the Department of Health and Human Services.
Under the same laws, we must give you access to
information in your medical record. The laws also
permit us to keep certain information from you.
Required by Law. We must share medical
information if federal, state or local law requires us
to.
Public Health and Safety. We may share your
medical information for public health reasons.
These include:
to prevent or control disease, injury or
disability;
to report births and deaths;
to report child abuse or neglect;
to report information to the FDA about the
products it oversees;
to let you know that you may have been
exposed to a disease or may be at risk for
getting or spreading a disease or condition;
or
to your employer in certain limited
instances.
Abuse and Neglect. The law may require us to
report suspected abuse, neglect or domestic
violence to state and federal agencies. Your
information may be shared with these agencies for
this purpose. Generally, you will be told that we are
sharing this information with these agencies.
Health Oversight Activities. Certain health
agencies are in charge of overseeing health-care
systems and government programs or to make sure
that civil rights laws are being followed. We may
share your information with these agencies for
these purposes.
Legal Proceedings. If a court or administrative
authority orders us to do so, we may release your
health information and records. We will only share
the information required by the order. If we receive
HIP-33F
Revised November 25, 2013 will make effective 12/1/13
University of Louisville
Physicians
UofL Health Care Outpatient
Center
401 East Chestnut Street
Louisville, KY 40202
any other legal request, we may also release your
health information and records. However, for such
other requests, we will only release the information
if we are told that you know about it, and had a
chance to object and did not, or if we have received
confirmation that the party requesting the
information has agreed to protect it under an order
approved by a court or administrative authority.
Law Enforcement. We may share health
information if a law enforcement official asks for it:
to respond to a court order, warrant,
summons or other similar process;
to identify or locate a suspect, fugitive,
material witness or missing person; or
to obtain information about an actual or
suspected victim of a crime.
We may share information with a law enforcement
official:
if we believe a death was the result of a
crime;
to report crimes on our property; or
in an emergency.
Coroners, Medical Examiners and Funeral
Directors. We may share health information with a
coroner or medical examiner to identify a deceased
person or find the cause of death. We also may
release health information to funeral directors if they
need it to do their job.
Organ and Tissue Donation. If you are an organ
donor, we may release medical information to the
organizations in charge of getting, transporting or
transplanting an organ, eye or tissue.
Research. We may share your medical record with
researchers, without your permission, in very limited
situations. In most cases, a researcher must submit
his/her request to see your information to a special
group called the Institutional Review Board (“IRB”).
JOINT NOTICE OF PRIVACY
PRACTICES
University of Louisville Physicians
Organized Health Care Arrangement
Effective Date: April 14, 2003
Revised: December 1, 2013
The IRB will decide if it should allow the researcher
to use or share your information. Your medical
information also may be used by or shared with
researchers to prepare for research, but only under
strict conditions. Under similar strict conditions,
medical information about deceased people can be
used or shared.
To Prevent a Serious Threat to Safety. We may
use and share your medical information to prevent
a serious threat to your health and safety or the
health and safety of others.
Specialized Governmental Functions. We may
share your medical information and records with:
Authorized federal officials
for intelligence, counter-intelligence and
other national security activities authorized
by law; or
to protect the President.
Armed forces command authorities or the
Department of Veterans Affairs
to see if you are fit for military duty or
eligible for veterans health services; or
to see if you are medically fit to receive a
security clearance by the Department of
State.
Correctional facility or law enforcement
official or agency if you are an inmate or
under the custody of a law enforcement official
or agency, if necessary, to:
help the correctional facility provide you
with health care; or
protect the health and safety of you and/or
others.
Workers Compensation. We may share your
health information with agencies or individuals to
HIP-33F
Revised November 25, 2013 will make effective 12/1/13
University of Louisville
Physicians
UofL Health Care Outpatient
Center
401 East Chestnut Street
Louisville, KY 40202
follow workers compensation laws or other similar
programs.
WAYS WE MAY USE AND SHARE YOUR
HEALTH INFORMATION WHEN WE HAVE
GIVEN YOU A CHANCE TO OBJECT.
You have the right to agree or disagree to the
following uses of your medical information. If you
are not here or able to agree or disagree, we may
still use and share information if we think that it may
be best for you.
Individuals Involved in Your Care or Payment
for Your Care. We may share medical information
about you with your family members, friends, or any
other person you tell us who is involved in your
medical care or who helps pay for it.
Disaster Relief. We also may share medical
information about you to a disaster relief agency so
that your family can be told of your condition and
location.
In some circumstances, you may have a chance to
object to the sharing of information for this purpose.
OTHER USES AND SHARING OF YOUR HEALTH
INFORMATION REQUIRE YOUR WRITTEN
AUTHORIZATION.
Certain uses and sharing of your health information
that are not described in this notice will be made
only with your written permission, called an
Authorization. These include uses and disclosures
of psychotherapy notes, uses and disclosures of
your health information for marketing purposes, and
disclosures that constitute a sale of your health
information.
You may revoke your authorization at any time, but
it will not be effective for uses or disclosures that
have already taken place. To revoke an
authorization, you must write to the University of
JOINT NOTICE OF PRIVACY
PRACTICES
University of Louisville Physicians
Organized Health Care Arrangement
Effective Date: April 14, 2003
Revised: December 1, 2013
Louisville Physicians Privacy Officer at the address
listed below.
YOUR RIGHTS REGARDING YOUR HEALTH
INFORMATION.
You have certain rights regarding your health
information, described below. These rights apply to
the health information we keep. You must submit a
written request to use any of these rights. You can
send your written request to the University of
Louisville Physicians Privacy Officer at the address
given at the end of this notice.
Right to Request Special Communications. You
have the right to ask that we write or call you at a
different address or phone number and/or by a
different way. We will try to follow all reasonable
requests.
If you would like us to use a different address,
phone number or different way of reaching you, you
must ask for this in writing. We will not ask why you
want to do this. Your request must tell us how you
wish to be contacted.
Right to Inspect and Copy. You have the right to
read or get a copy of your health information, with
some exceptions. We may turn down your request
under certain circumstances. If we do so, you may
ask for a licensed health-care professional chosen
by us to review why we turned you down. We will
follow the reviewer’s decision.
Right to Request Changes. If you believe the
health information that we created is wrong or
incomplete, you may ask us to change it. You must
provide a reason why you want the change. We
cannot take out or destroy any information already
in your medical record. Under certain
circumstances, we are permitted to deny your
request for a change. If we do not agree to the
change, we will provide you with a letter explaining
the reason for our denial. You can then write us a
HIP-33F
Revised November 25, 2013 will make effective 12/1/13
University of Louisville
Physicians
UofL Health Care Outpatient
Center
401 East Chestnut Street
Louisville, KY 40202
letter if you disagree with our reason for denying the
changes. You can send this letter to the University
of Louisville Physicians Privacy Officer at the
address listed below. Your letter will be attached to
the information you wanted changed or corrected.
We may also send you a letter in response.
Right to an Accounting of Disclosures. We are
required to track who we share your health
information with under certain circumstances. You
have the right to ask for a copy of this list. Your
request must give a time period, which may not be
longer than 6 years.
If you would like to ask for a list of disclosures, you
must ask for it in writing. You must tell us the
date(s) you would like to see. The first list will be
given to you free. We are permitted to charge a
reasonable fee if you request an additional list of
disclosures in the same 12 month period. Your
right to receive this list is subject to certain
limitations and the law permits us to exclude certain
types of disclosures from the list we provide.
Right to Request Restrictions. You have the right
to ask for a restriction or limitation on the medical
information we use or share about you. We are not
required to agree to your request, with one
exception. We are required to agree when you ask
us to refrain from sharing your information with a
health plan, if the information pertains to a health
care item or service that you have paid for out of
pocket in full. For other requests, if we choose to
agree, we will follow your request unless the
information is needed to provide you with
emergency treatment. You must tell us the type of
restriction you want and to whom it applies.
Right to Receive Breach Notifications. In many
instances, you have the right to know if your
unsecured information has been lost, stolen, or
otherwise seen by people who do not usually have
the right to see it.
JOINT NOTICE OF PRIVACY
PRACTICES
University of Louisville Physicians
Organized Health Care Arrangement
Effective Date: April 14, 2003
Revised: December 1, 2013
Right to a Paper Copy of This Notice. You have
the right to a paper copy of this notice. Copies of
this notice will be posted and available at each
location where medical services are provided and at
www.uoflphysicians.com
CHANGES TO THIS NOTICE.
We reserve the right to change this notice. We
reserve the right to make the revised or changed
notice effective for your health information we
already have as well as any we get in the future.
Any changes in this notice will be posted on our
Web site at www.uoflphysicians.com
The revised notice also will be available at any of
the locations where University of Louisville
Physicians offers services.
WHAT IF I HAVE QUESTIONS OR NEED TO
REPORT A PROBLEM?
If you have any questions about this notice or about
how your health information is used or shared by us
please contact the University of Louisville
Physicians Privacy Officer by calling 502.588.4520
or 1.855.588.6001.
If you believe your privacy rights have been
violated, you may file a complaint with us.
To file a complaint, please contact the University of
Louisville Physicians Privacy Officer at
502.588.4520 or 1.855.588.6001 or write to the
Privacy Officer at PO Box 909, Louisville, KY
40201-0909. Please give as much information as
possible so that the complaint can be looked into
properly.
You may also file a complaint with the Secretary of
the Department of Health and Human Services.
Your care will not be affected if you file a
complaint, nor will any action be taken against
you.
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