Forms

ADULT PATIENT HISTORY

If today’s appointment is a Medicare Annual Wellness Visit or a Complete Physical, we will review your preventive health needs. If you need care for a new or ongoing medical problem, it may be addressed today, but a co-pay will be required. In some cases, a separate appointment may need to be scheduled.

Ask our staff if you Would like Advance Care Directives information

IMMUNIZATIONS & HEALTH MAINTENANCE (give date of last shot/exam)

Women only: (please give date of last exam)

Men only: (Please give date of last exam)

Family History of Major Medical Problems (lf deceased, list cause and age of death)

Circle any of the following symptoms you currently experience

EMERGENCY CONTACT & HIPAA FORM

Healthcare Information Portability and Accountability Act (HIPAA) information

By signing this form, you authorize Nextlevel Complete Family Care Inc to release protected health information for the above-named patient according to the instructions below.

I authorize this information to be released to: 

If you do not wish to authorize anyone, please enter “N/A” in the required fields.

NOTICE OF PRIVACY PRACTICES
Effective Date: 09/23/2013  Publication Date: 09/23/2013

This notice describes how medical information about you may be used and disclosed
And how you can gain access to this information. Please review it carefully.

NEXTLEVEL COMPLETE FAMILY CARE, INC.

Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (name, address, phone, etc), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under The Privacy Rule.

Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any question with our Staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices.

We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, on its website.

You have the right to authorize other use and disclosure.

This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication.

This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.), designated by you. You must inform us in writing, using a form provided by our practice.

how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and copy your PHI.

This means you may inspect, and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your PHI.

This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment, in certain cases, we may deny your request for restriction. You will have the rights to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You may have the right to request an amendment to your protected health information.

This means you may request an amendment of your PHI for long as we maintain this information in certain cases, we may deny your request.

You have the right to request a disclosure accountability.

This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of office.

You have the right to receive a privacy breach notice.

You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under Privacy Complaints.

NOTICE OF PRIVACY PRACTICES
Effective Date: 09/21/2013  Publication Date: 09/23/2013

How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions.
We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Special Notices

We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan sponsor. You have the right to opting out of such special notices, and each such notice will include instructions for opting out.

Payment

Your PHI be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Health Operations

We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Health Information Organization

The practice may elect to use a health information organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To others involved in Your Healthcare

Unless you object, we may disclose to a member of your family, a close friend or any other person, that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest, based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest, in this case PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures

We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners, medical examiners and funeral directors; organ donation; national security; worker’s compensation. We are also permitted to use or disclose your PHI if required by the Department of Health and Human Services in order to investigate or determine our compliance with the Privacy Rule.

Privacy Complaints

You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy at:

We will not retaliate against you for filing a complaint.

Address: 10450 NW 33rd ST
#: Suite 205
City: Doral
State: FL
Zip Code: 33172

HIPAA – PATIENT CONSENT FOR USE OF DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

EMAIL/TEXT MESSAGE TO MOBILE PHONE CONSENT FORM

Purpose: This form is used to obtain your consent to communicate with you by email/mobile text messaging regarding your Protected Health Information. NEXTLEVEL COMPLETE FAMILY CARE, INC. (NLCFC) offers patients the opportunity to communicate by email/mobile text messaging. Transmitting patient information by email/mobile text messaging has a number of risks that patients should consider before granting consent to use email/mobile text messaging for these purposes. NLCFC will use reasonable means to protect the security and confidentiality of email/mobile text messaging information sent and received. However, NLCFC cannot guarantee the security and confidentiality of email/mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

IN CASE OF EMERGENCY: Please call 911 or proceed to the nearest emergency room.
Do not use this way of communication for that purpose.

Attachment Section:
Please upload important documentation required by the office for your records.