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New Patient Demographics Form

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Sex*
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Title
Marital Status
Emergency Contact Information
Are you under the care of a physician now?
Child Responsible Party/ Subscriber Information
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Health Insurance Information
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Medicare Information
Patient Payment Agreement for Services Rendered
I, , agree to all medical and professional services I receive from Acute Alternative Medical Group. I am responsible for any deductible and co-payment assigned by my health insurance. All other subsequent balance will be my full responsibility. I hereby authorize Lyn Campbell, M.D. and staff to render professional advice, medical treatment, and any procedures necessary and desirable by mutual agreement.
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Privacy Summary
9/01/11

 

Acute Alternative Medical Group (AAMG) is committed to preserving the privacy of your protected health information, in other words, information that can be used to identify you, such as your name, social security number, address, and telephone number. In fact, we are required by law to protect the privacy of your protected health information and to provide you with notice describing:

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS THIS INFORMATION

 

PLEASE REVIEW IT CAREFULLY

 

We are required by law to inform you how we use or disclose to other your protected health information for purposes of providing, coordinating or arranging for your care, consultation between providers, the payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your services. AAMG may not use or disclose any more of your protected health information than is necessary.

(We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization).

As someone we provide services to, you have important rights relating to 1) inspecting and copying your protected health information that we maintain, 2) amending or correcting that information, 3) obtaining an accounting of our disclosures of your information, 4) requesting that we communicate with you confidentially, 5) requesting that we restrict certain uses and discloses of your information, and 6) informing us if you think your rights have been violated.

We provide you a detailed Notice of Privacy Practices, which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top of this page indicates the date of the most current Notice in effect. You have the right to receive a copy of our most current Notice. If you have not yet received a copy of our current Notice and would like one, please ask and we will provide you with a copy.

If you have any questions, concerns or complaints about the Notice or you want more information please contact the Executive Assistant Eliza Combie at 184C Estate Diamond Ruby, Christiansted, VI 00820.

My signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996.

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