Patient Information
Contact Information
Emergency Contact
Only female patients
Authorization:
I certify that I (or my dependent)
have health plan coverage with the
- Mapfre
- Triple-S
- Triple-S Advantage
- Pan American Life
- MMM
- MCS Classicare
- Humana
- Humana Medicare Advantage
- First Medical
- BlueCross. BlueShield.
- Medicare.gov
- UnitedHealthCare
- MCS
- utm Healthcare
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company and assign Dr. Luis B. Rivera Nazario as the recipient of payment for services received, if any, that would otherwise be provided to me. I understand that I am responsible for payment of such services, regardless of whether or not it is covered by my health plan. I authorize the Doctor to use any information necessary for the payment of said benefits. I authorize the use of this signature in any document that is necessary to submit claims to the health insurance plan or myself.
Information in Case of Accident (If not an accident, please continue in the patient's record)
Patient History
Use the scale of 1-10 (with # 1 being the better and # 10 the worst)
Please mark each of the conditions that you suffer or suffered in the present or past
Our Policy
Here are the policies of our office. We ask that you carefully read and sign the document. Please mark the first five policies in the box provided.
If you need to cancel any of your appointments, we ask that you call 24 hours in advance to make the relevant changes. If an emergency arises, please call when you know that you will not be able to attend your appointment. In case of not being able to arrive at the time of your appointment, you will be offered to come the same day, at a more convenient time for you, according to availability. If you miss 4 appointments in a row, all your appointments will be canceled.
Since part of the treatment is to make the patient feel relaxed during their appointment, we ask that you keep your cell phone quiet at all times and take your calls outside the waiting room and treatment area.
Our office hours are from 8:00 am to 7:00 pm, with a lunch break from 12:00 pm to 1:00 pm. The last appointment time is at 6:00 pm, after 6:30 pm no one will be attended without the exception of person. Patients who visit our office for the first time, for a result report or for an evaluation study, they are attended from 8:00 am to 5:00 pm.
It is the patient's responsibility to inform our office of any changes in their medical plan and / or coverage (card change, cancellation of the medical plan, etc.). If not notified, the charges not covered will be the responsibility of the patient. If you do not have an appointment or want to change the date and time of the same, please call before arriving at our office to be able to attend you on time.
In our office there are several types of treatments for different conditions. If the doctor determines that you need any specific treatment, you must wait in turn for the availability of the designated room. Various products and treatments are provided in the office depending on the patient's condition. Some of these are not covered by medical plans. From the doctor recommending a treatment that is not covered by your plan, the cost will be indicated before providing the service.
Referrals
The best token of appreciation that a patient can make to our Chiropractic Center is the referral of family and friends. We give our word that you will be treated and treated with the same quality, trust and service that you received. We thank you in advance.
10 day rule (50% discount)
During the first 10 days of your treatment in our office, any member of your family can make an appointment with the doctor for a general chiropractic evaluation with a 50% discount on the initial evaluation study. Please tell the secretary in advance when you want to make an appointment for a family member
Privacy Policy
This policy will be effective from September 23, 2014.
Your information. Your rights. Our responsibilities
This notice describes how medical information about you that is in our possession may be used, disclosed, and how to access it. Please review it carefully and sign at the end in the space provided.
Your rights:
Obtain a copy of your paper or electronic medical record, (2) Correct or amend your paper or electronic medical record, (3) Require that your communications be confidential, (4) Ask us to limit the information we share. (5) Get a copy of those with whom we have shared your information. (6) Obtain a copy of this privacy notice. (7) File a complaint if you think your rights have been violated.
Your rights:
When it comes to your medical information, you have certain rights: (1) You may request to see or obtain a paper or electronic copy of your file or any other medical information that we have about you; (2) We can provide you with a copy or summary of your medical information, usually within 30 days of your request, for which we may charge a reasonable fee based on our costs; (3) Ask us to correct aspects of your medical file that you consider incorrect, we may decline your request but we must respond to you why within a period of no more than 60 days after the denial; (4) You can ask us to call or write you at an alternate address, and we must agree to any reasonable request in that regard; (5) You can ask us not to use certain information for your treatment, payment or for our operations. But we are not required to agree if we think it may affect your medical care; (6) If you pay for a consultation or procedure entirely out of your pocket, you can ask us not to share this information with your health insurance. We must agree unless there is a law that requires us to share the type of information in question; (7) You can ask for a list of with whom or how many times we have shared your health information in the last 6 years and why. We must respond but we do not have to include the times that we share it for purposes of your treatment, payment and operations of your health plan and some others such as the times that you have requested that we communicate it. A list of this type will be provided per year at no charge to you but a payment will be charged according to our costs for a second request made before twelve months after the last request; (8) You have the right to obtain a paper copy of this privacy notice even if you have agreed to receive it electronically; (9) You can choose to have another individual act for you, if someone is your legal guardian, if you have given a power of attorney through an attorney, that person will be able to exercise your rights and make health decisions for you. We will ensure that this person has this authority before taking any action; (10) You also have the right to file a complaint if you think your rights have been violated, by contacting us at the address that appears in this document, or you can do so with the Office of Civil Rights of the United States Department of Health and Human Services United by sending a letter to: 200 Independence Ave., SW, Washington, DC 20201, by calling 877-696-6775, or visiting the web address:
www.hhs.gov/ocr/privacy/hipaa/complaints;> we will not take action
against you for filing a complaint.
Our Uses and Disclosures
How do we typically use and share your information? When treating you medically: We may use your information for the purposes of the work in this practice, and (2) To contact you when necessary. (3) We can share it with other professionals who are treating you, and (4) We use it to bill for the services we provide you. Who else can we use or share your information with? We are allowed and required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in law before we can share your information for those purposes. For information about it consult:
www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
Your Choices:
You can make certain choices about how we share your information, for example when: We tell your family and friends information about your condition; The
we disclose to provide disaster relief; We include you in a hospital directory; To provide you with mental health care; When and how we market our services; If we sell your information; Or we raise funds.
Our Uses and Disclosures
We may share your information in the following settings: To treat you medically; (2) Running our healthcare provider operation; (3) Bill for services offered to you; (4) Cooperate with public health matters and situations of safety or danger; (5) Do research or studies, (6) Comply with any law that requires us to do so; (7) Respond to organ and tissue donation requests; (8) To collaborate with medical examiners or funeral directors; (9) To respond to matters related to employment compensation; (10) With law enforcement agencies and other government requests; (11) To respond to lawsuits and / or legal actions.
Your Choices
For certain health information, you can notify us of your preferences as to what information we share. If you have a clear idea of how you want your information to be shared in the following scenarios, talk to us and we will tell you what to do. You can tell us if you want to share your information with your family, close friends, or others involved in your care; (2) Share your information in a disaster situation, (3) Include your information in a hospital directory. (4) In the event that you are not in a position to tell us your preferences because, for example, you are unconscious, we will proceed to share the information that we think will act in your best interest. (5) We may also share your information in a situation where it is necessary to avoid an imminent threat to your health or safety.
In the following cases we will never share your health information unless you tell us otherwise in writing: (1) For marketing purposes, (2) Sale of your information, (3) Share most of your psychotherapy notes. (4) In the case of fundraising we may contact you but you have the right to request that we not contact you again.
(2) Support for matters related to health and safety
We may share your information in situations such as the following: (A) Prevent disease, (B) Help in the collection of products that are being requested back by their manufacturers or distributors, report adverse drug reactions, report suspected abuse, neglect or domestic violence. (C) Reduce or prevent a serious threat to health or safety. (D) Also for study and research purposes. (E) We can share your information for health research, (F) Comply with laws that require us to evaluate our performance, (G) also when an individual dies we can share information with coroners, medical examiners and funeral service administrators, ( H) As part of an employment-related compensation request, (I) for law enforcement purposes or with law enforcement officials, (J) Respond to organ and tissue donation requests, (K) With agencies that oversee the health function with permission from the government, (L) For government operations such as military, national security and presidential protective services. (M) It can be shared for purposes of answering a legal action or lawsuit, under the order of a court, administrative order with sufficient authority or in response to a summons.
Our responsibility:
(1) We are required by law to maintain the privacy and security of your protected health information. (2) We will notify you promptly if a security breach occurs that compromises the privacy of your information. (3) We must follow the security requirements and practices outlined in this notice and provide you with a copy of them. (4) We will not use or share your information in any way other than as described unless you tell us otherwise in writing. If you do not allow the above, you can change your decision at any time. Let us know in writing if you want to change your decision.
Changes to the terms of this notice:
We can change the terms of this notice, and the changes will apply to all information we have. The new notice will be available upon request in our office or through our page
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
The Privacy Officer is:
Gabriela M. Cabrera Paler You can contact her via e-mail at centroquiropracticorivera@yahoo.com or by phone at 787-294-2600.
I have received, read and understood this privacy practices document and for the record I sign them at:
Dear Patient,
We wish to inform you that Dr. Luis B. Rivera Nazario does not:
1.) Medical reports, either for health plans or social security, or court. You will only be given a copy of your medical record.
2.) He does not offer his services as an expert.
3.) Does not perform condition certifications