New Patient Biopuncture Form

New Patient Biopuncture Form-Free PDF

  • Date:23 Oct 2020
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D Medications,Medication Reason for taking,E Surgeries. Date Type of surgery,F Females Pregnancies and outcomes. Pregnancies date of delivery Outcome, What was the date of the beginning of your last menstrual period. 5 Family Health History,Significant health problems of relatives. Deaths in immediate family,Cause of parents or siblings death Age at death.
6 Social and Occupational History,D Recreational activities Level of Exercise. E Lifestyle,Tobacco Use Alcohol Use,Illicit Drug Use. 7 Activities of Daily Living, A Do you live alone Yes No B Do you need any help with your daily activities Yes No. I have read the all of the above information and certify it to be true and correct to the best of my knowledge. Patient Signature Date,Doctor s signature Date,Informed Consent For Injection Therapy. Biopuncture is a treatment used to deliver ultra low doses of natural products that are FDA regulated into the. tissue under the skin into a muscle myofascial trigger point ligament tendon or periosteum Treatments are. typically well tolerated without any adverse reactions Sometimes a series of injections are recommended for a. satisfactory outcome, Potential side effects include but are not limited to.
Local skin irritation and bruising,Swelling and or pain at the injection site. Infection at the injection site, Injury to nerves muscles or blood vessels at the injection site. Allergic reactions which if left untreated could result in death. By signing this document I am agreeing to the treatments I have been informed of the risks and benefits. involved with this treatment and understand the potential side effects. I have informed the provider of any allergies medications and previous injections. In addition I am verifying that I am not pregnant and am not being treated for the following AIDS cancer. embolism DVT liver cirrhosis tuberculosis or any other infectious disease. I have read the above consent I have also had an opportunity to ask questions about its content and by signing. below I agree to the above named procedures I intend this consent form to cover the entire course of treatment. for my present condition and for any future conditions for which I may seek treatment. Patient Name Print please Patient Signature,Parent Signature if under 18. Witness to above signature Date Signed,Barbara Kura FNP. Wurtsboro Acupuncture Chiropractic Physical Therapy PLLC. General Pain Index Questionnaire, We would like to know how much your pain presently prevents you from doing what you would normally do Regarding each category.
please indicate the overall impact your present pain has on your life not just when the pain is at its worst. Please circle the number which best describes how your typical level of pain affects these six categories of activities. 1 Family at home responsibilities such as yard work chores around the house or driving the kids to school. 0 1 2 3 4 5 6 7 8 9 10,completely able totally unable. to function to function, 2 Recreation including hobbies sports or other leisure activities. 0 1 2 3 4 5 6 7 8 9 10,completely able totally unable. to function to function, 3 Social activities including parties theater concerts dining out and attending other social functions with friends. 0 1 2 3 4 5 6 7 8 9 10,completely able totally unable.
to function to function, 4 Employment including volunteer work and homemaking tasks. 0 1 2 3 4 5 6 7 8 9 10,completely able totally unable. to function to function, 5 Self care such as taking a shower driving or getting dressed. 0 1 2 3 4 5 6 7 8 9 10,completely able totally unable. to function to function, 6 Life support activities such as eating and sleeping.
0 1 2 3 4 5 6 7 8 9 10,completely able totally unable. to function to function,PATIENT NAME DATE,Score 60 Benchmark 5. NOTICE OF PRIVACY PRACTICES, Wurtsboro Acupuncture Chiropractic Physical Therapy PLLC. Barbara Kura FNP,P O Box 490 80 Sullivan Street,Wurtsboro NY 12790. Phone 845 644 4426 Fax 845 644 4428,Email healingtouchalternative gmail com.
Effective Date 10 01 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 THIS NOTICE CAREFULLY. This Notice of Privacy 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 PHI 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, USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION. Treatment We may use and disclose your personal information to provide you with treatment or services For example. we may use your health information to prescribe a course of treatment or make a referral We will record your current. healthcare information in a record so in the future we can see your medical history to help in diagnosing and treatment. or to determine how well you are responding to treatment We may provide your health information to other health. providers such as referring or specialist physicians to assist in your treatment Should you ever be hospitalized we may. provide the hospital or its staff with the health information it requires to provide you with effective treatment. Payment We may use and disclose your health information so that we may bill and collect payment for the services that. we provided to you For example we may contact your health insurer to verify your eligibility for benefits and may need. to disclose to it some details of your medical condition or expected course of treatment We may use or disclose your. information so that a bill may be sent to you your health insurer or a family member The information on or. accompanying the bill may include information that identifies you and your diagnosis as well as services rendered any. procedures performed and supplies used Also we may provide health information to another health care provider such. as an ambulance company that transported you to our office to assist in their billing and collection efforts. Health Care Operations We may use and disclose your health information to assist in the operation of our practice For. example members of our staff may use information in your health record to assess the care and outcomes in your case. and others like it as part of a continuous effort to improve the quality and effectiveness of the healthcare and services we. provide We may use and disclose your health information to conduct cost management and business planning activities. for our practice We may also provide such information to other health care entities for their health care operations For. example we may provide information to your health insurer for its quality review purposes. Other Permitted and Required Uses and Disclosure will be made only with your consent authorization or opportunity to. object unless required by law 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 HEALTH INFORMATION RIGHTS, The following are statements of your rights with respect to your protected health information. Right to Obtain a Paper Copy of This Notice You have the right to a paper copy of this Notice. of Privacy Practices at any time Even if you have agreed to receive this notice electronically. you are still entitled to a paper copy, Right to Inspect and Copy You have the right to inspect and copy medical information that. may be used to make decisions about your care Usually this includes medical and billing records but does not include. psychotherapy notes You have a right to information that is stored electronically that is not in EHR software including. information stored in MS Word Excel PDF plain text and other electronic formats To inspect and copy medical. information you must submit a written request to our privacy officer We will supply you with a form for such a request If. you request a copy of your medical information we may charge a reasonable fee for the costs of labor postage and. supplies associated with your request We may not charge you a fee if you require your medical information for a claim. for benefits under the Social Security Act or any other state or federal needs based benefit program If your medical. information is maintained in an electronic health record you also have the right to request that an electronic copy of your. record be sent to you or to another individual or entity We may charge you a reasonable cost based fee limited to the. labor costs associated with transmitting the electronic health record You have a right to have this information with in 30. days of receipt of your request, Right to Amend If you feel that medical information we have about you is incorrect or incomplete you may ask us to.
amend the information You have the right to request an amendment for as long as we retain the information To request. an amendment your request must be made in writing and submitted to our privacy officer In addition you must provide. a reason that supports your request We may deny your request for an amendment if it is not in writing or does not. include a reason to support the request In addition we may deny your request if you ask us to amend information that. was not created by us unless the person or entity that created the information is no. longer available to make the amendment, is not part of the medical information kept by or for name of provider. is not part of the information which you would be permitted to inspect and copy or. is accurate and complete, If we deny your request for amendment you may submit a statement of disagreement We may reasonably limit the. length of this statement Your letter of disagreement will be included in your medical record but we may also include a. rebuttal statement, Right to an Accounting of Disclosures You have the right to request an accounting of disclosures of your health. information made by us In your accounting we are not required to list certain disclosures including. disclosures made for treatment payment and health care operations purposes or. disclosures made incidental to treatment payment and health care operations however. if the disclosures were made through an electronic health record you have the right to. request an accounting for such disclosures that were made during the previous 3 years. disclosures made pursuant to your authorization,disclosures made to create a limited data set. disclosures made directly to you, To request an accounting of disclosures you must submit your request in writing to our privacy officer Your request must.
state a time period which may not be longer than six years and may not include dates before April 14 2003 Your request. should indicate in what form you would like the accounting of disclosures for example on paper or electronically by. email The first accounting of disclosures you request within any 12 month period will be free For additional requests. within the same period we may charge you for the reasonable costs of providing the accounting of disclosures We will. notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs. are incurred Under limited circumstances mandated by federal and state law we may temporarily deny your request for. an accounting of disclosures, Right to Request Restrictions You have the right to request a restriction or limitation on the medical information we use. or disclose about you for treatment payment or health care operations You also have the right to request a limit on the. medical information we communicate about you to someone who is involved in your care or the payment for your care. You have a right to restrict certain disclosures of Protected Health Information to a health plan where you have paid out. of pocket in full for the healthcare item or service As noted above we are not required to agree to your request If we do. agree we will comply with your request unless the restricted information is needed to provide you with emergency. treatment To request restrictions you must make your request in writing to our privacy officer In your request you must. tell us what information you want to limit whether you want to limit our use disclosure or both and to whom you want. the limits to apply, Right to Request Confidential Communications You have the right to request that we communicate with you about. medical matters in a certain way or at a certain location For example you can ask that we only contact you at work or by. e mail To request confidential communications you must make your request in writing to our privacy officer We will. accommodate all reasonable requests, Right to Receive Notice of a Breach We are required to notify you by first class mail or by email if you have indicated a. preference to receive information by e mail of any breaches of Unsecured Protected Health Information as soon as. possible but in any event no later than 60 days following the discovery of the breach Unsecured Protected Health. Information is information that is not secured through the use of a technology or methodology identified by the. Biopuncture is a treatment used to deliver ultra low doses of natural products that are FDA regulated into the tissue under the skin into a muscle myofascial trigger point ligament tendon or periosteum Treatments are typically well tolerated without any adverse reactions Sometimes a series of injections are recommended for a satisfactory outcome Potential side effects include but are

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