*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Personal / Family History
Your Medical History
Please indicate if you have a history of the following:
Please indicate if your family has a history of the following. If none, please select "NONE". Only include parents, grandparents, siblings and children:
If you use other tobacco products (other than cigarettes), do you use:
Alcoholic drinks per day:
Have you ever been addicted to or dependent on drugs or pain medication?
Do you live alone?
Do you have a living will?
Have you had the pneumococcal vaccine?
Have you had the flu vaccine?
Please indicate if you have had any of the following surgeries:
Have you ever had an adverse reaction/problem with anesthesia?
Have you had blood relatives with anesthesia problems?
Review of Systems
Please select all the symptoms you are currently experiencing. If no symptoms, please select None.
JOINT NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
About this Notice
This Notice tells you about the ways we may use and disclose protected health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your protected health information. We are required by law to:
- maintain the privacy of your protected health information;
- notify you of any breaches of your unsecured protected health information;
- give you this Notice describing our legal duties and privacy practices with respect to your protected health information; and
- follow the terms of our Notice that are currently in effect.
We will make a good faith effort to obtain from you a written acknowledgement of receipt of this Notice. We have developed an Acknowledgement of Receipt of Notice of Privacy Practices form to obtain this acknowledgement (HP Form 01). If we cannot obtain written acknowledgement from you, we will use the form to document our attempt and the reason why the written acknowledgement was not signed by you. This Notice, and all applicable forms referenced herein, are available by contacting the Privacy Officer or accessing the practice's website.
Definition of terms
When we say "you" in this Notice, this refers to the patient or resident who is the subject of the protected health information. When we say "we", "our", or "us", this refers to The Physicians' Group, LLC and HPI Physicians, LLC.
Who will follow this Notice
The privacy practices described in this Notice will be followed by all health care professionals, employees, clinical staff, trainees, students, volunteers, and business associates of our organization. We provide you this Notice on behalf of each of The Physicians' Group, LLC, HPI Physicians, LLC and other health care practitioners that practice at either The Physicians' Group, LLC or HPI Physicians, LLC. Each of these providers has agreed, as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations. This enables us to better address your health care needs. Each of these providers makes up an Organized Health Care Arrangement (OHCA) for purposes of HIPAA. The members of this arrangement will follow this Notice when they treat you.
When we are permitted or required to use or disclose your PHI without obtaining your authorization or giving you an opportunity to object
The following sections describe the purposes for which we are permitted or required to use or disclose your protected health information without obtaining your prior authorization and without offering you an opportunity to object.
For treatment and services
We may use and disclose your protected health information to provide you with health care treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, students, or other personnel involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also share protected health information about you with our other personnel or outside health care providers, agencies, or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab work, and x-rays. We may also disclose protected health information about you to people who may be involved in your continuing care after you leave us, such as other health care providers, transport companies, community agencies, and family members.
We may use and disclose your protected health information to others for purposes of receiving payment for treatment and services you receive. For example, a bill may be sent to you or a third-party payor, such as an insurance company, a health plan, or Medicare/Medicaid. The information on the bill may contain information that identifies you, your diagnosis, and treatment, or supplies used in the course of the treatment and services you receive.
For health care operations
We may use and disclose your protected health information for our operations purposes. These uses and disclosures are generally made for quality of care and training. Your protected health information may also be used or disclosed to comply with laws and regulations, accreditation purposes, patients' and residents' claims, grievances or lawsuits, health care contracting relating to our operations, legal services, business planning and development, business management and administration, the sale of all or part of our senior living facilities to another organization, underwriting and other insurance activities, and to operate our senior living facilities. We may also disclose information to doctors, nurses, technicians, clinical and other students, and our personnel for performance improvement and educational purposes. For example, we may compile your protected health information, along with that of other individuals, in order to allow a team of our staff members to review that information and make suggestions concerning how to improve quality of care provided by us.
To business associates
We may disclose your protected health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf.
We may use and disclose your protected health information for research purposes when an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information has approved the research.
For limited data sets
Federal law allows us to create a "limited data set" - a limited amount of protected health information from which almost all identifying information, such as your name, address, Social Security number, and medical record number, has been removed - and share it with those who have signed a contract promising to use it only for research, health oversight, and health care operations purposes and protect its privacy.
As required by law
We may use and disclose your protected health information when required to do so by federal or state law.
To avert a serious threat to health or safety
We may use and disclose your protected health information when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to help stop or reduce the threat.
To the United States or a foreign military
If you are a member of the armed forces, we may disclose your protected health information to military authorities as authorized or required by law. We may also release protected health information about foreign military personnel to the appropriate military authority as authorized or required by law.
For workers' compensation
We may use and disclose your protected health information for workers' compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illnesses.
For public-health disclosures
We may use and disclose your protected health information for public-health purposes. These purposes generally include, but are not limited to, the following:
- preventing or controlling disease (such as tuberculosis), injury, or disability;
- notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
- reporting vital events, such as deaths;
- notifying the appropriate authority as authorized or required by law if we believe a patient or resident has been the victim of abuse, neglect, or domestic violence; or
- to report reactions to medications or problems with products.
To law enforcement
If asked to do so by law enforcement, and as authorized or required by law, we may disclose protected health information:
- to identify or locate a suspect, fugitive, material witness, or missing person;
- about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
- about a death suspected to be the result of criminal conduct;
- about criminal conduct at any of our senior living facilities; and
- in case of a medical emergency, to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.
To coroners, medical examiners, and funeral directors
We may disclose your protected health information to coroners, medical examiners, or funeral directors so they can carry out their duties.
For national-security and intelligence activities
As authorized or required by law, we may disclose your protected health information to authorized federal officials for intelligence, counterintelligence, and other national-security activities.
For protective services for the U.S. president and others
As authorized or required by law, we may disclose your protected health information to authorized federal officials so they may conduct special investigations or provide protection to the U.S. president, other authorized persons, or foreign heads of state.
If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may disclose your protected health information to the correctional institution as authorized or required by law.
For organ/eye/tissue donation
If you are an organ, eye, or tissue donor, we may disclose your protected health information to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ, eye, or tissue donation and transplantation.
When we are required to give you notice or an opportunity to object in order to use or disclose your protected health information
We may use and disclose your protected health information for the following purposes. However, except in emergency situations, we will inform you of our intended action prior to making any such uses and disclosures and will, at that time, offer you the opportunity to object.
For care and notification purposes
We may disclose to your relatives or close personal friends or other individuals you identify any protected health information that is directly related to such person's involvement in the provision of, or payment for, your care, and we may also do so if you become deceased. We may also use and disclose your protected health information for the purpose of locating and notifying your relatives, close personal friends, or personal representative of your location and general condition or death, and to organizations that are involved in those tasks during disaster situations. If you object to the foregoing, you have the option to restrict our uses and disclosures of your protected health information (HP Form 04).
Your rights regarding your protected health information
Your protected health information is our property. You have the following rights, however, regarding protected health information we maintain about you.
Right to inspect and copy
With certain exceptions (such as psychotherapy notes, information collected for certain legal proceedings, and protected health information restricted by law), you have the right to inspect and/or receive a copy of your protected health information as long as we maintain that information. Your request must be submitted in writing to the Privacy Officer (HP Form 05). We may deny your request, under certain circumstances, such as if we believe it may endanger you or someone else. You may request that we designate a licensed health care professional to review the denial. By Oklahoma statute, we may charge you $.50 per page, plus our postage costs. If your record contains any item that requires a photographic process to copy, such as a x-ray or photograph, we may charge you $5.00 per image. If we can deliver records electronically, we will provide the records in electronic form and will charge $0.30 per page, up to a maximum of $200 per request.
Right to request an amendment or addendum
If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information or add an addendum (addition to the record). You have the right to request an amendment or addendum for as long as the information is kept by or for us. Your request must be submitted in writing (HP Form 06). If we accept your request, we will tell you we agree and we will amend your records. We cannot take out what is in the record. We add the supplemental information. With your assistance, we will notify others who have the incorrect or incomplete protected health information. If we deny your request, we will give you a written explanation of why we did not make the amendment and explain your rights. We may deny your request if the protected health information:
- was not created by us (unless you provide us a reasonable basis to believe the person or entity that created the protected health information is no longer available to respond to your request);
- is not part of the health and billing records kept by or for us;
- is not part of the information which you would be permitted to inspect and copy; or
- is determined by us to be accurate and complete.
Right to an accounting of disclosures
You have the right to receive a list of the disclosures we have made of your protected health information for the previous six years. Your request must be submitted in writing to the Privacy Officer (HP Form 07). This list will not include disclosures made:
- to carry out treatment, billing, and health care operations;
- to you or your personal representative;
- incident to a permitted use or disclosure;
- to parties you authorize to receive your protected health information;
- to those who request your information through the practice directory;
- to your family members, other relatives, or close personal friends who are involved in your care, or who otherwise need to be notified of your location, general condition, or death;
- for national security or intelligence purposes;
- to correctional institutions or law enforcement officials; or
- as part of a "limited data set."
You must state the time period for which you want to receive the accounting, which may not be longer than six years. The first accounting you request in a 12-month period will be free. We may charge you for responding to any additional requests in that same period.
Right to request restrictions
You have the right to request a restriction or limitation on the protected health 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 protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or a close personal friend. For example, you could ask that we not disclose information to a family member about a treatment you had or a service you received at one of our facilities. Your request for a restriction must be submitted in writing (HP Form 04).
We are not required to agree to your request unless you or someone on your behalf paid for the services in full out-of-pocket, the protected health information pertains solely to such services, and the disclosure is for our payment or health care operations and is not otherwise required by law. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment or we are required by law to disclose it. We are allowed to end the restriction if we tell you. If we end the restriction, it will only affect protected health information that was created or received after we notify you.
Right to request alternate communications
You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only at home or only by mail. Please contact the Privacy Officer to complete the necessary form (HP Form 08). If you want us to communicate with you in a special way, you will need to give us details about how to contact you, including a valid alternative address. You also will need to give us information as to how billing will be handled. We will not require you to explain why you want this special way of communicating. We will honor reasonable requests. However, if we are unable to contact you using the requested ways or locations, we may contact you using any information we have.
Right to request a disclosure
You have the right to request that we disclose your protected health information for reasons not provided in this Notice. For example, you may want your lawyer to have a copy of your medical records. Your request must be submitted in writing to the Privacy Officer (HP Form 02). You may revoke an authorization to disclose at any time by written notice (HP Form 03).
Right to a paper copy of this Notice
You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may also obtain an electronic copy at the practice website.
Other uses of protected health information
Most uses and disclosures of psychotherapy notes, uses and disclosures of protected health information for marketing purposes, and disclosures that constitute a sale of protected health information require your written authorization. Other uses and disclosures of protected health information not covered by this Notice will be made only with your written authorization. If you provide us authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. However, uses and disclosures made before your revocation are not affected by your action. If your revocation relates to research, researchers are allowed to continue to use the protected health information they have gathered before your revocation if they need it in connection with the research study or follow-up to the study.
Our right to check your identity
For your protection, we may check your identity whenever you have questions about your treatment or billing activities. We will check your identity whenever we get requests to look at, copy, or amend your records or to obtain a list of disclosures of your protected health information. Forms for each of these requests will be available from our departments that handle medical records, as well as from the Privacy Officer. The forms are also available on our practice website.
Future changes to our privacy practices and this Notice
We reserve the right to change our privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for protected health information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice on our website. In addition, at any time you may request a copy of the Notice currently in effect.
If you believe your privacy rights have not been followed as directed by federal regulations and state law or as explained in this Notice, you may file a written complaint with us (HP Form 09). You may also file a written complaint with the U.S. Department of Health and Human Services, Office for Civil Rights ("OCR"), by sending it by mail or fax to the OCR regional office for the state where the alleged violation took place. The contact information for the OCR regional offices can be found at http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html. A written complaint may also be filed electronically at http://www.hhs.gov/ocr/privacyhowtofile.html. You will not be penalized for filing a complaint in good faith.
If you have any questions or would like further information about this Notice, please contact the Privacy Officer: Juliann Sullivan, 14024 Quail Pointe Drive, Oklahoma City, OK 73134, (405) 419-8441.
Below is a list of the practice locations for only The Physicians' Group, LLC affiliated doctors:
(1) 10001 S. Western, Suite 101, Oklahoma City, OK 73139
(2) 10021 S. Western, Oklahoma City, OK 73139
(3) 10021 S. Western, Suite 200, Oklahoma City, OK 73139
(4) 105 S. Bryant, Suite 407, Edmond, OK 73034
(5) 105 S. Bryant, Suite 410, Edmond, OK 73034
(6) 13190 NE 23rd, Choctaw, OK 73020
(7) 1705 S. Renaissance Blvd., Suite 120, Edmond, OK 73013
(8) 262 Quadrum Dr., Oklahoma City, OK 73108
(9) 3110 SW 89th Street, Suite 102, Oklahoma City, OK 73159
(10) 3110 SW 89th St., Suite 200E, Oklahoma City, OK 73159
(11) 3115 SW 89th Street, Oklahoma City, OK 73159
(12) 6922 S. Western, Suite 101, Oklahoma City, OK 73139
Below is a list of the practice locations for both The Physicians' Group, LLC and HPI Physicians, LLC affiliated doctors:
(1) 1616 S. Kelley, Edmond, OK 73013
(2) 3048 SW 89th Street, Suite B, Oklahoma City, OK 73159
(3) 3212 SW 89th Street, Suite 100, Oklahoma City, OK 73159
(4) 6205 N. Santa Fe, Suite 200, Oklahoma City, OK 73118
(5) 3100 SW 89th Street, Oklahoma City, OK 73159
(6) 7530 NW 23rd Street, Bethany, OK 73008
(7) 10001 S. Western Suite 202 Oklahoma City, OK 73139