Call Today: 248.624.9800
Call Today: 248.624.9800

New Patient Form











(e.g.: BCBSM, Medicare, etc.)




(e.g.: BCBSM, Medicare, etc.)






(e.g.: I have a wound on my leg that won't seem to heal. I need to be evaluated by a wound specialist. etc.)



Other information may be required (check box that applies to you below)

Is this a Worker's Compensation case?

Patient's Name: Date of Birth:

Date of Injury: Claim Number:

 
 
 
Insurer: Adjuster's Name:

Address: City: State: Zip:

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Case Manager:

Address: City: State: Zip:

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Attorney:

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Is this an Auto Accident case?

Patient's Name: Date of Birth:

Date of Injury: Claim Number:

 
 
 
Insurer: Adjuster's Name:

Address: City: State: Zip:

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Case Manager:

Address: City: State: Zip:

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Attorney:

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Encompass HealthCare and Wound Medicine, PLLC

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice please contact Kitty Carpenter at 248-624-9800.

OUR PLEDGE REGARDING YOUR HEALTH INFORMATION:

We understand that health information about you is personal. We are committed to protecting your health information. We create a record of the care and services you receive at Encompass HealthCare and Wound Medicine (herein referred to as “Medical Practice,”) as well as any divisions, departments, or affiliated companies. We need to record to provide you with the best care possible and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Medical Practice, whether made by Medical Practice personnel or by your personal doctor. This notice describes the Medical Practice’s privacy practices and that of all its departments and units, any volunteer we allow to help you while you are at the Medical Practice, all employees, staff and Medical Practice Personnel, to anyone authorized to enter information into your Medical Practice chart, and services of any of our subsidiaries and/or affiliates (if applicable.) This notice will tell you about the ways in which we may use and disclose your health information. We also describe your rights and certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

• make sure that health information that identifies you is kept private;
•give you this notice of our legal duties and privacy practices with respect to your health information and;
•follow the terms of the notice that is currently in effect.

WHO FOLLOWS THIS NOTICE:
This Notice describes the Medical Practice’s operations and how our employees and staff use and disclose health information.

HOW WE MAY USE & DISCLOSE HEALTH INFORMATION ABOUT YOU:

The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what we mean and try to give some examples. Not every use of disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the Medical Practice. For example, a doctor treating you for a minor surgery may need to know if you have diabetes because diabetes may slow the healing process. Different departments may also share health information about you in order to coordinate the different information of the things you need, such as prescriptions, lab work and x-rays. We also may disclose health information about you to people outside the Medical Practice who may be involved in your medical care after you leave the Medical Practice, such as family members, clergy or others we use to provide services that are part of your care.

For Payment: We may use and disclose health information about you so that the treatment and services you receive at the Medical Practice may be billed to and payment may be
collected from you, an insurance company or a third party. For example, we may need to give your health plan information about the treatment you received at the Medical Practice so your health plan will pay us or reimburse you for that treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

For Health Care Operations: We may use and disclose health information about you for Medical Practice operations. These uses and disclosures are necessary to manage and operate the Medical Practice and make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about may of our patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may also combine the health information we have with health information from other medical practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.

With regard to behavioral health and substance abuse information, Michigan law requires that we obtain your permission to disclose such information, regardless of whether it will be used for treatment, payment, or health care operations.

Appointment Reminders: We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or medical care at the Medical Practice.

Treatment Alternatives: We may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved In Your Care or Payment for Your Care: We may release health information about you to a friend or family member who is involved in your medical care. We may also tell your family or friends your condition and, if applicable, that you are in a hospital.

As Required by Law: We will disclose medical information about you when required to do so be federal, state or local law.

SPECIAL SITUATIONS:

We may disclose health information about you as required by state or federal laws and regulations relating to any or all of the following, as such may apply to you.

1. Community/public health activities and reports such as disease control, abuse or neglect and health and vital statistics.
2. To avert a serious threat to you health or safety and to protect the health and safety of the public. Any disclosure would only be to someone able to help prevent the threat.
3. Administrative oversight for such things as audits, investigations, licensure or determining cause of death.
4. Court order or other legal processes related to law enforcement activities.
5. Organ and tissue donation and transplant reports as required by regulatory organizations as necessary to facilitate organ or tissue donation and transplant.
6. Workers’ Compensation or other rehabilitative activities reporting as required by law or insurers in order to provide benefits for work related or victim injuries or illnesses.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.

To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to the Medical Practice. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request, as allowed by law or regulation. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by the Medical Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the Medical Practice.

By checking this box, I have reviewed the above statements and I agree


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2300 Haggerty Road, Suite 1190 | West Bloomfield, Michigan 48323 | 248-624-9800