Houston Medical Group

I,  , understand that as part of my health care, Houston Medical Group, originates and maintains paper and/or electronic records regarding my health history, exam and test results, treatment and plans for future management. I understand this information serves as:

• A basis for planning my care and treatment,
• A means of communication among health professionals who contribute to my care,
• A source of information for applying my diagnosis and surgical information to my bill,
• A means by which a third-party-payer can verify that services billed were provided, and
• A tool for clinic operations, i.e. assessing quality & competence of medical professionals.

I understand and have been provided with a Notice of Information Practices that provides a more complete account of information uses and disclosures. I understand I have the following rights:

• The right to review the notice prior to signing this consent,
• The right to object to the use of my health information for directory purposes, and
• The right to restrict how my records are used or disclosed to carry out treatment, payment or health care operations.

I understand that Houston Medical Group is not required to agree to the restrictions requested. I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I understand that by refusing to sign this consent or revoking this consent, this clinic may refuse to treat me, as permitted by Section 164.506 of the Code of Federal Regulations.

I understand Houston Medical Group reserves the right to alter notice and practices prior to completion, in accord with Section 164.520 of the Code of Federal Regulations. If Houston Medical Group alters notice, if requested, a copy will be sent to the address I supply (U.S. mail or, if I agree, e-mail).

I wish to have the following restrictions to the use or disclosure of my health information:

I understand for this organization’s treatment, payment or care operations, it may be necessary to release my health records to another entity; I consent to disclosure for these uses, including via fax.

Your health is a serious personal matter and we understand that confidentiality is of utmost importance. To ensure your complete privacy, we implemented and follow specific strict security protocols and processes. We only use the highest level of customer and web site security features to guarantee your privacy and security. It is our policy to never allow any 3rd party access to any of your personal financial or medical information. If you have a question on our security processes or protocols please contact us immediately.

Your Test Results - You and only you receive your test results unless you direct us in writing to forward your results to a medical practitioner or an additional 3rd party. Although some positive results such as HIV are required to be reported to certain government agencies, only the minimum required information will be reported.

YOUR PRIVACY IS IMPORTANT TO US AND WE USE EVERY CARE TO SECURE YOUR PRIVACY RIGHTS!

HIPAA: Health Insurance Portability and Accountability Act - This notice describes how medical information about you may be disclosed and how you can get access to this information. Please review this carefully. In compliance with the 1996 Congressional Act to protect the privacy of patients’ protected health information, we will safeguard all client/patient information and will disclose or share only minimal information necessary for the following purposes:

Treatment: Information regarding current or past health information necessary for the agency to carry out appropriate care of the clients requesting home care services which may include, but is not limited to:

History and physical, progress notes, laboratory reports, x‑ray results, operative reports, consultation reports, hospital discharge reports, hospital DNR, to be obtained from any clinic, hospital, skilled nursing facility, physician office or health care agency involved in the patient/client’s present and future care.

Payment: Information requested by the Insurance Company, necessary for the processing of claims for payment of services.

Operations: Review of medical records by any peer review organization, accrediting body, state or regulatory body for statistical or agency evaluation purposes only. Any information disclosed will be held in strict confidence and not used for any public disclosure.

If you feel that your privacy rights have been violated you may contact us and ask for the Director or Operations. The director will investigate all claims and will provide you with a written report of their findings within 10 days. If you are not satisfied with the report and corrective action taken, the Director will provide you with an appropriate state or federal organization address and or telephone numbers to file a complaint.

We will maintain a log for each patient we service which will list what information was released and for what purpose. The patient has the right to review this log upon request.

I have been informed of and acknowledge that participation in physical medicine/therapy involving flexibility, strength, balance, agility, and aerobic exercise, including the use of equipment and devices, is a potentially hazardous activity. I have also been informed of and acknowledge that participation in physical medicine can be a test of a person’s physical and mental limits and that such participation and training poses potential risks of serious bodily injury or death.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I hereby accept the responsibility for any harm, injury or damage that may result from chiropractic adjustments and other chiropractic procedures, including various modes of physical medicine. I hereby waive, release, absolve, indemnify and agree to hold Houston Medical Group, its officers, employees and affiliates for any claim arising out of any injury to me, whether the result of negligence or any cause. I voluntarily and knowingly acknowledge, accept and assume these risks.

I have read this waiver and release of claims and covenant not to sue. I am aware that this is an agreement not to sue and constitutes a complete release of liability by me and by the program participant. I acknowledge that I am signing this document of my own free will, with full knowledge of the risks being assumed.

I agree to the following:

1. My participation in chiropractic treatment, physical medicine and training is strictly voluntary.
2. My participation in each and every exercise and activity within the physical medicine training program is voluntary and I may choose not to participate, or limit my participation, in any exercise or activity at any time.
3. I am personally responsible for my own safety while participating in the physical medicine program. I will pace myself to maintain a level of participation that is safe and comfortable for me.
4. I will advise my chiropractor/medical doctor/chiropractic assistant of any changes in my physical or mental health prior to participation in each session.
5. My chiropractor/chiropractic assistant/medical doctor is available to answer any questions or concerns that I might have regarding my participation, activities, or safety.
6. I will seek further direction or explanation of anything that I do not fully understand, or that causes me concern.

INFORMED AND CONSENT TO MEDICAL SERVICES: I have been informed of and acknowledge that participation in medical services, involving physical exam, physician prescribing services, medical diagnostic laboratory and testing services, can potentially have emergency medical condition arising from treatment program or treatment adversely affecting.

PREGNANCY DISCLAIMER: I do hereby state and assure that it is not possible that I am or might be pregnant at this time. I understand that this facility and /or employees will take every precaution to safeguard my well-being. Therefore, I release Houston Medical Group and/or whomever they may designate and/or their assistants from any and all responsibility and liability regarding this matter.

MINOR’S RELEASE: I hereby give written authorization to whoever is designated to administer such treatment as prescribed by himself or the designated doctor and/or assistant(s) to my minor child. I hereby certify that I have read and fully understand the above mentioned authorization for treatment, the reasons why treatment is considered necessary, its advantages, and possible complications, if any, which were explained to me by the doctor and/or a designated assistant. I further certify that no guarantee of assurance has been made as to the results that may be obtained. I also release and authorize whoever is designated to release any medical information necessary in the processing of this claim to an insurance carrier(s) and/or attorney.

INFORMED CONSENT TO MEDICAL CONSULTATION AND TREATMENT: In general terms, I agree to receive a general medical consultation and treatment for my injury. I understand I may or may not be prescribed medications to help alleviate my pain. I understand expected results, common side effects, and possible risks may occur with use of medications.

I hereby accept the responsibility for any harm, injury or damage that may result from medical services and treatment provided by Houston Medical Group and entire organization.

I also agree to immediately go to the nearest hospital medical emergency room at the time of any type of medical emergency or medical condition that believes requires the immediate medical attention which arises from any treatment, service, products, prescription drug provided by Houston Medical Group., any employee, agent, independent medical physician, or physician assistant and nurse that covering for the medical physician.

I also understand that I may refuse to take medication when it is offered and/or revoke consent at any time. I understand that if such refusal would be unsafe to the consumer or others, medication may be given involuntarily. I understand I have the right to file human rights complaint or to seek judicial protection of consumer’s rights or privileges as provided by law.

Telemedicine involves the use of electronic communications to allow patients at a location remote from the health care provider, or health-care providers at different locations to share patient medical information to help improve patient care. Providers may include main doctors, specialists, and/or subspecialists (distant specialist). The information may be used for diagnosis, therapy, follow-up, and/or education. It may also include any of the following: patient medical records, medical images, live two-way audio and video, output data from medical devices and sound and video films.

Electronic systems used will incorporate network and software security protocols to protect private patient information and imaging data. It will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.

Expected Benefits: Improved access to medical care, obtaining expertise of a distant specialist.

Possible Risks: information may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision-making by the physician and consultant(s). Delays in medical evaluation and treatment could occur due to equipment problems or failures. If this occurs, I understand that it is my responsibility to obtain follow up care or assistance. In very rare instances, security protocols could fail, causing a breach of private personal medical information. A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

By giving my consent:

• I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. I understand that no information obtained in the use of telemedicine, which identifies me, will be disclosed to other entities without my consent.
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
• I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction. I understand that I may receive copies of this information for a reasonable fee.
• I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My medical team has explained the alternatives to my satisfaction.
• I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state or out of the country.
• I understand that it is my duty to inform my medical team of electronic interactions regarding my care that I may have with other healthcare providers.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
• I understand that I may need to be seen in person if, in my provider’s discretion, it is necessary for any reason.

I have read and understand the information provided above regarding telemedicine. I have discussed it with my provider as may be designated, and all of my questions have been answered to my satisfaction. If this informed consent is being signed in advance of an upcoming telemedicine visit, I understand that this document must be signed before the visit can occur, however I can call my clinic with any questions prior to signing. I hereby give my informed consent for the use of telemedicine in my medical care. I hereby approve the use of telemedicine in the course of my diagnosis and treatment.