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Westwood Primary Care PLLCPatient InformationNameDate Of BirthSS#Marital Status SexEthnicity/RaceParent/Guardian (if applicable)AddressCityStateZipPhone (H) (W) (C)E-Mail AddressEmergency ContactNameRelationshipPhone NumberPharmacy Name:Financial ResponsibilityPrimary holder Relationship to PatientPhone(H) (C) (W)Date Of BirthSS#Primary Holder Of PolicyName DOBSS
Primary InsuranceInsurance CompanyPhone #ID#Group#Secondary InsuranceInsurance CompanyPhone #ID#Group#Consent To TreatmentI am the patientI am the parent/guardian of the patientI hereby authorize such medical care, treatment, and diagnostic test as may be recommended andunderstand there is no warranty or guarantee of result or sure. This consent will remain in effect until Iwithdraw my consent in writing. I understand that medical students and nurse practitioner students, undersupervision, may be involved in my care.Signature of Patient/Parent/Guardian: Date:
ACKNOWLEDGEMENT OF RECEIPT OF JOINT NOTICE OF PRIVACY PRACTICEThis joint notice of Privacy Practices applies to the privacy practices of the affiliated Entities and theEntities Participating in the Organization Health Care Arrangement. These Entities include: WestwoodPrimary Care PLLC. This form is used to document (a) an individual’s acknowledgment of receipt of ourJoint Notice Of Privacy Practices of (b) when we have not obtained this acknowledgement our good faitheffort to obtain the acknowledgement.Section A: IndividualSection B: Acknowledgement of Receipt of Joint Notice Of Privacy Practices I Acknowledge that I have a Joint Notice Of Privacy Practices from Westwood Primary Care PLLC.Signature: Date:Personal Representative’s Name: Relationship to individual:Section C: Good Faith Effort to Obtain Acknowledgment Of ReceiptDescribe the reason why the individual would not/could not sign thisform:Signature:Date:Print Name:Title:Include this Acknowledgement Of Receipts in the individuals Medical RecordsAssignment Of BenefitsI am the patientI acknowledge full responsibility for the payment of service received and agree to pay them in full at the time ofservice unless other arrangements have been made. I understand that insurance coverage is an arrangement betweenthe insurance carrier and the patient. Westwood Primary Care PLLC will assist in billing my insurance company, butI am ultimately responsible for payment should my insurance fail to pay within a reasonable amount of time.I authorize Westwood Primary Care PLLC to bill my insurance or third-party payer and receive payment directlyfrom them for services rendered. I also authorize Westwood Primary Care PLLC to release information as requiredto my insurance or third-party payer (including my employer’s worker compensation carrier), for the purpose ofdetermining benefits. I understand that such records may include information regarding HIV/AIDS testing,substance abuse and /Or mental health issues. A photocopy of a faxed copy of this authorization shall be deemed asvalid as the original.My signature signifies acceptance of all terms in the Assignment Of Benefits.Signature of Patient/Parent/Guardian: Date:Staff Witness to signature: Date WitnessedI am the parent/guardian of the patient Other Relationship
MAGNOLIA FAMILY MEDICINE/ WESTWOOD PRIMARY CARE PLLCFINANCIAL POLICYWE DO NOT FILE ANY WORKERS COMPENSATION CLAIMSWE DO NOT FILE ANY CAR ACCIDENT/MOTORCYCLE ACCIDENT CLAIMSWe are doing everything possible to hold down the cost of medical care. You can help a great deal by eliminatingthe need for us to bill you. The following is a summary of our payment policy.ALL PAYMENT ARE EXPECTED AT THE TIME OF SERVICE: Payment is required at the time services arerendered unless other arrangements have been made in advance. This includes applicable copayments, coinsuranceand deductible payments for participating insurance companies. We accept cash, personal checks (in-state only),Visa, MasterCard, Discover, And American Express.THERE IS A SERVICE CHARGE FEE OF 30.00 FOR ALL RETURNED CHECKSLATE FEES: Payment is required at the time services are rendered unless other arrangements have been made inadvance. This includes applicable copayments for payment prior to scheduling appointments. THERE WILL BE A 30.00 MONTHLY LATE FEE CHARGE ON ANY BALANCE AFTER 30 DAYS. All accounts more than120 days past due will be transferred to a collections agency and you will be responsible for all agency fees andwould adversely affect your credit rating with the credit bureaus.INSURANCE: We bill participating insurance companies as a courtesy to you. You must present your most recentinsurance card at the time of service. You are expected to pay your deductible/copayments at the time of service infull. VERIFICATION OF BENEFITS IS NEVER A GUARANTEE OF PAYMENT; ALL CLAIMS ARESUBJECTED TO THE TERMS OF YOUR PLAN AFTER FILING YOUR CLAIM. If we have NOT receivedpayment from your insurance company within 45 days from the date of service, you will be expected to pay thebalance in full. You are responsible for all charges and all late fees. Your time of service receipt includes allinformation necessary for submitting claims to your insurance company. We do bill secondary insurance companiesof applicable.WE DO NOT FILE WORKERS COMPENSATION CLAIMS. WE DO NOT FILE CARACCIDENT/MOTORCYCLE ACCIDENT CLAIMS.MANAGED CARE: if you are enrolled on a managed care insurance plan (i.e. HMO) you must present your mostrecent insurance card with our primary care physicians name on it. If you do not have it at the time of service wewill reschedule your appointment for a later date. Referrals will be given only after consultation with one of ourdoctors. You must receive a referral from our office before seeing specialist. NO retroactive referrals will be given.OUT OF NETWORK We accept a variety of insurance plans, and due to the complexity of managed care contracts,we suggest patients to verify our doctors participation of IN NETWORK STATUS with their insurance companyprior to making the appointment at MAGNOLIA FAMILY MEDICINE.REFUNDS Overpayments will be refunded upon written request within 30 days to the responsible party.MISSED APPOINTMENTS/LATE CANCELLATIONS: Broken appointments represent a cost to us, to you andother patients who could have been seen in the set aside for you. Cancellations are requested 24 hours prior to theappointment. We reserve the right to charge for missed/late- cancelled appointments a minimum fee of 30.Abuse of scheduled appointments may result in the discharge from the practiceI have read and understand WESTWOOD PRIMARY CARE PLLC FINANCIAL POLICY. I agree to assigninsurance benefits to Westwood Primary Care PLLC whenever necessary. I also agree that if it becomes necessaryto forward my accounts to a collections agency I will be responsible for all collection fees.Signature of patient/authorized representative Date
Westwood Primary Care, PLLCPatient Consent for Use Email CommunicationsTo better serve our patients, this office has established an email address for some form of communications.For routine matters that do not require immediate responses, please feel free to contact us atinfo@mydocmd.com. Please remember however that this form of communication is not appropriate for useof in an emergency. The turnaround time for the routine patient communication is within 48 hours. Theservice provider may delay message delivery. Should you require urgent or immediate attention, thismedium is not appropriate.When sending email, please put the subject of your message in the subject line so we can process it moreefficiently. Also be sure to put your name, patient date of birth and return telephone number in the body ofthe message. We also ask that you acknowledge receipts of email coming from this office by using the autoreply feature.Communication relating to diagnosis and treatment will be filed in your medical record.This office is dedicated to keeping your medical record information confidential. Despite our best efforts,due to the nature of email, third parties may have access to message. When communicating from work, youshould be aware that some companies consider email corporate property and your messages may bemonitored. Even when emailing from home, you may feel that access to your email is not well controlled,so you should take that into consideration. In addition you should be aware that although addressed to me,my staff and or colleagues would have access to this information.Email address:I understand that this office will not be responsible for information loss or delay or breaches in confidentiality thatare due to technical factors beyond this office’s control.I understand and agree to the above email policy.By signing below, you are agreeing that we may send medical related corresponded to you via email and that wemay respond to your email to us via email.Patient Signature Witness (optional)DateAll article and any forms, checklist, guidelines and material are for generalized information only and should not be reviewed orreferred to as primary legal source nor constructed as establishing medical standards of the care for the purpose of litigation,including expert testimony. They are intended as resource to be selectively used and always adapted with the advice of thedistributed with the understanding that neither Texas Medical Liability Trust Nor Texas Medical Insurance Company is engagedin rendering legal services.@TMLT Revised 04/13/2016
Magnolia Family Medicine Clinic PoliciesOur clinic has clarified these policies and procedures to answer the common questions regarding your care.Magnolia Family Medicine your new medical home welcome you. We are honored that you are trusting us withyour health. Provide each patient with the best care possible within a friendly, professional atmosphere reminiscentof an era when doctors and their staff treated patients with compassion and dignity rather than as numbers orinsurance statistics. Keeping you in good health is our primary concern. The patient guide that follows willfamiliarize you with our clinic and will answer questions you might have.LABWe use Quest Diagnostics and MH labs and we are very satisfied with both. We encourage patients to sign up foronline access to lab results directly through patient portal. Our patient portal information system allows patient toview lab and imaging result. Abnormal lab results necessitate an appointment.MEDICATION REFILLSMedications are prescribed with specific refills based treated, Please do not call our office for refills. It is the patientresponsibility to schedule an appointment for additional refills.ADD/ADHD MEDICATIONSStimulant (Ritalin, Adderall, Vyvanse, Etc) are written on special state controlled prescriptions. We require aquarterly visit, including a urine drug screen. Refills of these medications require an Office visit every 3 months.CONTROLLED SUBSTANCE SCHEDULE III(Xanax, Ambien, Klonopin, Etc)Are subjected to routine urine drug testing and office visits at least every 3 months.TESTOSTERONE THERAPY Patients can receive testosterone injections at our clinic every 7-14 days. Such visitare billed to insurance companies as nurse visits.Quarterly visits with the provider and specific lab testing is required for any method of testosterone administration,whether topical or injected.NARCOTIC MEDICATIONSSchedule II medications, including Vicodin, Norco, Oxycodone, Dilaudid among others, are not routinely prescribedby our clinic. Management if chronic pain will be referred to a certified pain specialist.PRIOR AUTHORIZATION Prior authorizations for unapproved medications may incur an additional fee.PHONE MESSAGES Phone messages will be returned within 24 hoursIMMUNIZATION OF CHILDRENOur physicians encourages parents to carefully consider CDC-recommended vaccinations, but he welcomeschildren, including ones not immunized. Our clinic does, however, request a signed waiver from a patient orguardian.Thank You again for your trust.(Patient Signature) Date
MAGNOLIA FAMILY MEDICINEDISCLOSURE OF PHYSICIAN OWNERSHIP INTERESTNOTICE TO PATIENTSPlease carefully review this notice.In order to allow you to make a fully-informed decision about your health care, the physicians ofMAGNOLIA FAMILY MEDICINE (the “Practice”) would like to inform you that at some point duringthe course of your treatment, the providers may refer you to alliance MRI to perform imaging studies. TheSleep Specialist of The Woodlands. The practice wishes to advise you that Dr Elhajj has a directownership interest in:Alliance MRI1011 Medical Plaza Drive Suite 120Spring Texas 77380Sleep Specialist Of The Woodlands6912 Fm 1488 Suite B Magnolia tx 77354All of the practice’s physicians will make referrals to laboratories, diagnostic imaging centers orhospitals, based upon the best interest of a patient’s health and any other factors that a patient would likehis or her physicians to consider. Regardless of any ownership interest or compensation arrangement thata physician may have with a particular laboratory or other facility.You, as a patient, have the right to choose the provider of your healthcare services and the laboratoriesand other facilities where you receive services or treatment. For information about alternativelaboratories, please ask your physicians affiliated with the practices.If you have any questions concerning this notice, please feel free to ask your physicians or any member ofour staff. We welcome you as a patient and value our relationship with you.By signing below, you acknowledge that you have read and fully understand this notice.Signature of Patient Signature of Parent or GuardianPrint Name of Patient /Guardian Date
Magnolia Family MedicinePatient Centered Medical Home Patient CompactA Patient Centered Medical Home: is a trusting partnership between a doctor-led healthcare team and aninformed patient. It includes an agreement between the doctor and the patient that acknowledges uWe trust you, our patient to: Tell us what you know about your health and illness Tell us about your need to concerns Take part in planning your care Follow the care plan that is agreed upon, or let us know why you cannot so we can try to help andchange the plan Tell us what medications you are taking and ask for refill at your office visit when you need one Let us know when you see other doctors and what medications they prescribe you on or change Ask other physicians/specialist/facilities to send us a report about your care when you see them Learn about your insurance so you know what it covers Keep your appointment as scheduled, or call and let us know you cannot at least 24 hours in advance Pay your share of the visit fee at the time of service Give us feedback so we can improve our serviceAs we build your Medical Home you will notice some changes in the way we provide care, but manythings will stay the same.
We will continue to: Provide you with your own doctor who knows you and your family whenever he/she is available Respect you as an individual, we will not make judgement based in race, religion, sex, or disability Respect your privacy your medical information will not be shared with anyone unless you give uswritten permission or it is required by law. Provider care given by the team of people led by your doctor Give the care you need when you need it Give the care that meets your needs and fits with your goals and values Have a doctor on call 24 hours 7 day a week Take care of short, illness, long-term disease and give advice to help you stay healthy Tell you about your health and illness in a way you can understand Over the next several months, youmay notice that: We ask your health care goal is or what you want to do to improve your health We used current best evidence in decision making about your care and offer support for selfmanagement of your health and healthcare We ask you to help us plan your care and let us know if you think you can follow the plan We will give you a written copy of the care plan The learn care members are doing more and / or different parts of the care We may ask you to have blood test done before your visit so the doctor has the results at the time ofyour visit. We may offer you’re a chance to join in a special type of doctor visit called a “group visit” We can continue to increase the use of technology in the way we manage your healthcare in the wayssuch as E-prescriptions, E-Messaging , and online bill pay (Via EMR, and Patient Portal)As part of our Patient Centered Medical Home orientation, we will ask you to acknowledge your agreementto the above and we will acknowledge our agreement to you: Either you or your doctor may end thispartnership at any time. If you choose to end the partnership please notify us and tell us why. If your doctordecides to stop seeing you, we will notify you with an explanation as to why. With your written permission,we will forward a copy of your health records to your new physician.Patient SignatureDate Of BirthToday’s Date
Dear patient,We are pleased to introduce AMS laboratories, LLC , PrevMed and Frontera asdiagnostic testing companies. Your doctor has partnered with AMS Laboratories,LLC and Frontera in order to provide a more comprehensive approach to yourhealth care. Their trained board certified physicians, licensed nurse and medicaltechnicians will be performing some of the following diagnostic tests:Nerve conduction studiesUrodynamic studiesVideonystagmographyNeurocognitive (and ADHD) testingSleep Studies (and CPAP equipment)Autonomic nervous system testingManual Muscle TestingUltrasoundEEGBased on answers your provided on your health history update, your doctor mayorder one or more of these diagnostic test to further evaluate your condition.Many diagnostic tests could be performed in your doctors office for yourconvenience. Sleep studies and other specialty testing will be performed at a labnear your area.Please expect and welcome their call, They will arrange appointment times at yourearliest convenience.INITIALS:
Notice of Privacy PracticesMAGNOLIA FAMILY MEDICINEAs required by the privacy regulations created as a result of the Health Insurance Portability andAccountability Act of 1996 (HIPPA).This notice is describes how health information about you (as a patient of this practice) may be used anddisclosed and how you can get access to your individually identifiable health information. Please reviewnotice carefully.A. Our commitment to your Privacy:Our practice is dedicated to maintain the privacy of you individually identifiable health information (alsocalled protected health information, or PHI). In conducting our business, we will create records regardingyou and the treatment and services we provide to you. We are required by law to maintain theconfidentiality of health information that identifies you. We also are required by law to provide you withthis notice of our legal duties and the privacy practices that we maintain in our practice concerning yourPHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have ineffect at the time.We realize that these laws are complicated, but we must provide you with the following importantinformation: How we may use and disclose your PHI Your privacy rights in your PHI Our obligations concerning the use and disclosure of your PHIThe terms of this notice apply to all records containing your Phi that are created or retained by ourpractice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision oramendment to this notice will be effective for all of your records that our practice has created ormaintained in the past, and for any of your records that we may create or maintain in the future. Ourpractice will post a copy of our current Notice in our offices in a visible location at all times, and you mayrequest a copy of our most current Notice at any time.We may use and disclose your PHI in the following ways:The following categories describe the different ways in which we may use and disclose your PHI1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to havelaboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Wemight use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacywhen we order a prescription for you. Many of the people who work for our practice- including, but notlimited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist othersin your treatment. Additionally, we may disclose your PHI to other who may assist in your care, such asyour spouse, children or parents ONLY after you sign a release form. Finally, we may also disclose yourPHI to other health care providers for purposes related to you treatment.2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for theservices and items you may receive from us. For example, we may contact your health insurer to certifythat you are eligible for benefits (and for what range of benefits), and we may provide your insurer with
details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. Wealso may use and disclose your PHI to obtain payment from third parties that may be responsible for suchcost, such as family members. Also, we may use your PHI to bill you directly for services and items. Wemay disclose your PHI to other health care providers or entities to assist in their billing and collectionefforts.3. Health care operations. Our practice may use and disclose your PHI to operate our business. Asexamples of the ways in which we may use and disclose your information for our operations, our practicemay use your PHI to evaluate the quality of care you received from us, or to conduct cost-managementand business planning activities for our practice. We may disclose your PHI to other health care providersand entities to assist in their health care operations.4. Appointment reminders. Our practice may use and disclose your Phi to contact you via telephone/emailto remind you of an appointment.5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatmentoptions ofalternatives.6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you ofhealth- related benefits or services that may be of interest to you.7. Release of information to family/friends. Our practice may release your PHI to a family member that isinvolved in our care, or who assists in taking care of you only after we obtain written consent from you.For example. A parent or guardian may ask that a babysitter take their child to the pediatrician’s office fortreatment of a cold. In this example, the babysitter may have access to this child’s medical informationonly after the parent/guardians consent.8. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do soby Federal, state or local law.9. Military. Our Practice may disclose your PHI if you are a member of U.S. or foreign military forces(including veterans) and if required by the appropriate authorities.10. National security. Our practice may disclose you PHI to federal and national security activitiesauthorized by law. We also may disclose your PHI to federal officials in order to protect the president,other officials or foreign heads of state, or to conduct investigations.11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officialsif you are an inmate or under the custody of a law enforcement official. Disclosure for these purposeswould be necessary: (a) for the institution to provide health care service to you, (b) for the safety andsecurity of the institution and/or (c) to protect your health and safety or the health and safety of otherindividuals.12. Workers compensation. Our practice may release your PHI for workers’ compensation and similarprograms.B. Use and disclosure of your PHI in certain circumstances:The following categories describe unique scenarios in which we may use or disclose your identifiablehealth information:
1. Public health risks. Our Practice may disclose your PHI to public health authorities that are authorizedby law tocollect information for the purpose of: Maintaining vital records, such as births and deaths Reporting child abuse or neglect Preventing or controlling disease, injury or disability Notifying a person regarding potential exposure to a communicable disease Notifying a person regarding a potential risk for spreading or contracting a disease Reporting reactions to drugs or problems with products or devices Notifying individuals if a product or device they may be using has been recalled Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse orneglect of an adult patient(including domestic violence); however, we will only disclose this informationif the patient agrees or we are required or authorized by law to disclose this information Notifying your employer under limited circumstance related primarily to workplace injury or illness ormedical surveillance. 2. Health oversight activities. Our practice may disclose your PHI to a healthoversight agency for activities authorizedby law. Oversight activities can include, for example, investigations, inspections, audits, surveys,licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or otheractivities necessary for the government to monitor government programs, compliance with civil rightslaws and the health care system in general. 3. Lawsuits and similar proceedings. Our practice may use anddisclose your Phi in response to a court or administrative order, if you are involved in a lawsuit or similarproceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawfulprocess by another party involved in the dispute, but only if we have made an effort to inform you of therequest or to obtain an order protecting the information the party has requested. 4. Law enforcement. Wemay release PHI if asked to do so by law enforcement official; Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement Concerning a death we believe has resulted from criminal conduct Regarding criminal conduct at our offices In response to a warrant, summons, court order, subpoena or similar legal process To identify/locate a suspect, material witness, fugitive or missing person, In an emergency, to report a crime (including the location or victim(s) of the crime, or the description,identity or location of the perpetrator) 5. Deceased patient. Our practice may release PHI to a medicalexaminer or coroner to identify a deceased individual or to identify the cause of death. If necessary, wealso may release information in order for funeral directors to perform their jobs. 6. Organ and tissuedonation. Our practice may release you PHI to organizations that handle organ, eye or tissue procurementtransplantation, including organ donation banks, as necessary to facilitate organ or tissue donation andtransplantation if you are an organ donor. 7. Research. Our practice may use and disclose your PHI forresearch purposes in certain limited circumstances. We will obtain your written authorization to use your
PHI research purpose except when an internal Review Board Privacy Board has determined that thewaiver of your authorization satisfies all of the following conditions: A. The use or disclosure involves nomore than a minimal risk to your privacy based on the following: (i) and adequate plan to protect theidentifiers from improper use and disclosure; (ii) an adequate plan to destroy the justification for retainingthe identifiers or such retention is otherwise required by law); and (iii) adequate written assurances thatthe PHI will not be re-used or disclosed to any other person or entity (except as required by law) forauthorized oversight of the research study, or for other research for which the use or disclosure wouldotherwise be permitted;B. The research could not practicably be conducted without the waiver.C. The research could not practicably be conducted without access to and use of the PHI 8. Serious threatsto health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent aserious threat to your health and safety or health and safety of another individual or the public. Underthese circumstances, we will only make disclosures to a person or organization able to help prevent thethreat.D. Your rights regarding you PHI: You have the following rights regarding the PHI that wemaintain about you:1. Confidential communications. You have the right to request that our practice communicate with youabout your health and related issues in a particular manner or at a certain location. For instance, you mayask that we contact you at home, rather than work. In order to request a type of confidentialcommunication, you must make a written request specifying the requested method of contact, or thelocation where you wish to be contacted. Our practice will accommodate reasonable requests. You do notneed to give reason for you request.2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHIfor treatment, payment or health care operations. Additionally, you have the right to reques
the insurance carrier and the patient. Westwood Primary Care PLLC will assist in billing my insurance company, but I am ultimately responsible for payment should my insurance fail to pay within a reasonable amount of time. I authorize Westwood Primary Care PLLC to bill my insurance or third-party payer and receive payment directly
