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I, , acknowledge that I must present a valid ID at every office visit with ATX Robotic Surgery.
Patient Name
Patient Signature
Date
The undersigned hereby assigns to ATX Robotic Surgery, all rights, title and interest in any payment do and/or undersigned for medical care, services, or supplies described in any health-insurance claim form or statement issued by ATX Robotic Surgery. If my workers compensation, health insurance, or lawyer does not cover any portion of expenses accrued by services provided to the patient, the patient will be responsible for the remaining balance. The undersigned understands that this agreement will not eliminate or effect in anyway the obligation of the patient's responsibility for payment and/or undersigned to pay ATX Robotic Surgery for all services and supplies rendered, including, but not limited to, any copayments or deductibles required by a Health Care Program or plan.
My signature below acknowledges full understanding of payment for service being my (The treated patient) financial responsibility.
I, , acknowledge and accept the Assignment of Benefits detailed above.
Print Responsible Party's Name
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Responsible Party's Signature
Date
Print Patient Name
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Patient Signature
Date
| Effective as of | April/14/2003 |
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| Revised | April 25, 2020 |
This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, 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 protected health information. “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.
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.
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.
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.
You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.
You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.
You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached.
You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint.
We will not retaliate against you for filing a complaint.
SUDEEP BURMAN
PHONE: (512) 630-0070
COMPLIANCE OFFICER: Kelli Slayton
Email kelli@atxroboticsurgery.com
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.
I, , acknowledge that I have received Dr. Sudeep Dustin Berman MD Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my health care information for the following: treatment, payment, healthcare operations and others described and permitted uses and disclosures. I understand that I may contact the HIPAA privacy officer designated on the notice if I have questions or complaints. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the ATX Robotic Surgery Notice of Privacy Practices.
Print Responsible Party's Name
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Responsible Party's Signature
Date
Print Patient Name
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Patient Signature
Date
To the patient; you have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used in order to make your educated decision to undergo any suggested treatment or procedure after knowing the risks and Hazards involved. At this point in your care, no specific treatment plan has been recommended.This consent form is needed and necessary to perform the evaluation necessary to identify the appropriate treatment and or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations testing and treatment by signing below, you are indicating that one you consent to reasonable and necessary medical examinations, testing and treatment to this will continue even after a specific diagnosis has been made and treatment recommended, unless you state otherwise semicolon three you consent to treatment at the office or at any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing by yourself. You have the right at any time to discontinue services.
I certify I have read and fully understand the above statement and consent fully and voluntarily to their content. The information that I fill out in this intake packet I certify to be true and correct to the best of my knowledge, and hereby authorize this office to perform any necessary examinations and or treatment in accordance with Texas statutes and laws.
I, , acknowledge and accept the general consent for care and treatment consent and the HIPAA notice of privacy practices acknowledgement, as detailed above.
Print Responsible Party's Name
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Responsible Party's Signature
Date
Print Patient Name
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Patient Signature
Date
I, , understand that medical information is considered protected health information Phi under both federal and state privacy laws. By signing this form, I acknowledge that:
Print Responsible Party's Name
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Responsible Party's Signature
Date
Print Patient Name
( )
Patient Signature
Date
I, , understand that medical information is considered protected health information (PHI) under both federal and state privacy laws. By signing this form, I acknowledge that:
Print Responsible Party's Name
( )
Responsible Party's Signature
Date
Print Patient Name
( )
Patient Signature
Date
, have you had or have you ever been diagnosed with any of the following:
Implantables
Please list any medications that you are now taking. Include non prescription medications and vitamins or supplements. Blood thinners: .
Please list any previous surgeries you have had.
Please describe any other medical issues.
Allergies and Sensitivites
