HIPPA FORM

COVID-19 alert

CORONAVIRUS DISEASE (COVID-19) - UNITED STATES

OUR OFFICE IS TAKING SERIOUS PRECAUTIONS TO HELP LIMIT THE SPREAD OF COVID-19 OUT OF RESPECT FOR OUR IMMUNOCOMPROMISED PATIENTS, WE REQUIRE THAT EVERYONE WEAR A MASK WHEN COMING INTO OUR OFFICE.

EVERYONE'S TEMPERATURE WILL BE TAKEN BEFORE ENTERING OUR CLINIC. YOU WILL BE ASKED TO FILL OUT A COVID-19 QUESTIONNAIRE.

IF YOU HAVE ANY SYMPTOMS OF COVID-19 OR HAVE RECENTLY TRAVELED OUT OF THE AREA, PLEASE CALL OUR OFFICE @208-529-9292.

HIPPA FORM

PLEASE REVIEW IT CAREFULLY

ADDENDUM TO NOTICE OF USE AND DISCLOSURES*

THIS ADDENDUM PROVIDES SPECIFIC DIRECTIONS FOR USE AND DISCLOSURE

OF YOUR MEDICAL INFORMAITON

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Fuereza y dosis de la medicación

Nombre de la medicación

PATIENT NAME

STRENGTH AND DOSE OF MEDICATION

MEDICATION NAME

Free Text

ADDITIONAL PHI DISCLOSURE

I hereby provide authorization for the following persons to receive my PHI. If PHI (personal health information) is disclosed under your authorization to person(s) entities that are not subject to federal or state privacy laws, it may be redisclosed and no longer protected. The purpose of this disclosure of my PHI is "At my request". I authorize discloser of my PHI to the following person(s) entities:

entities

NON-DISCLOSURE

NON-DISCLOSURE

I DO NOT want the following types of my PHI disclosed. Additional I do not authorize disclosure of my PHI to the identified person(s)/entities:

Condition/Treatment/Test Result/Other:

Person(s)/Entity DO NOT disclose my PHI to:

FINANCIAL DISCLOSURE

FINANCIAL DISCLOSURE

I hereby provide authorization for the following persons/entities to receive and/or inquire about my Financial obligations associated with the care I have received.

FINANCIAL DISCLOSURE

HAVE READ AND UNDERSTAND

I have read, understand, and agree to all the provisions of this Financial Policy which includes your agreement for payment at time of treatment unless other arrangements are made prior to service or treatment. I hereby authorize the use and discloser of my individually identifiable PHI as stated in the Notice of Use and Disclosures except as excluded by this the addendum.

Patient Name

Authorized Signature

Date

If not signed by the patient, please indicate relationship:

FILL OUT IF YOU SELECTED OTHER

*This is an addendum to the NOTICE OF USE AND DISCLOSURES. All information on Notice of Use and Disclosures as well as the Financial Policy apply in association with this document

You can rely on the doctors at Idaho Allergy And Asthma Clinic in Idaho Falls, ID to treat your asthma and allergy symptoms. Our clinic assists both adults and children. Give us a call at 208-529-9292 to get more information or to schedule your appointment. Please click and download our patient forms below to bring to your appointment.

Click below to download the patient forms. You can send the completed forms to iaac100@gmail.com or carry a print-out of the completed forms to your appointment.

Allergy Testing Information