PATIENT ASSESSMENT
DATE OF INITIAL VISIT:
NAME:
SEX: M F
DATE OF BIRTH:
HEIGHT:
SSN:
WEIGHT:
Address: __________________________________________________________________________________
City/Town: ______________________________ State: ____________________ Zip Code: ________________
Home Phone: ______________________ Cell: ________________________ Work Phone: _____________________
E-mail Address: ____________________________________________________________________________
*If you do not wish to share your email or if you do not have an email, please initial _____________________
Language: _______________________ Race: ______________________ Ethnicity: _____________________
Work, circle one:
F/T
Marital Status, circle one:
P/T
Single
Retired
Married
Unemployed
Divorced
Widowed
Disabled
Other
Emergency Contact:
Name: ___________________________Relation: ___________________ Phone #: _____________________
Primary Care Physician: _____________________________________________________________________
Address: _______________________________________________ Phone #: __________________________
Referring Physician: ________________________________________________________________________
Address: ____________________________________________ Phone # _____________________________
How did you hear about us?
□ TV □ Radio □ Internet
□ Groupon □ Friend □ Event: ______________ □ Other: ______________
INSURANCE INFORMATION
Primary Insurance: _____________________________________ Copay Amount: ____________________
Identification#: _____________________________________ Group#: _____________________________
Policy Holder: ______________________________________________________ DOB: ________________
Employer: _____________________________ Employer’s Address: ________________________________
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Secondary Insurance: ___________________________________ Copay Amount: ____________________
Identification#: _________________________________________ Group#: __________________________
Policy Holder: ___________________________________________________________ DOB: ___________
Employer: __________________________________ Employer’s Address: ___________________________
Insurance Referral Required: Yes___ No___
Obtained: Yes____ No____
Guarantor:______________________________
WHICH LEG ARE YOUR COMPLAINTS LOCATED IN? (check one)
□ Right
□ Left
□ Both
HOW WOULD YOU DESCRIBE YOUR SYMPTOMS? (check all that apply)
□ Aching
□ Awakened at night
□ Bleeding from veins
□ Bulging
□ Burning
□ Cramping
□ Difficulty healing wounds
□ Edema
□ Fatigue
□ Heaviness
□ Itching
□ Painful
□ Restless Legs
□ Swelling
□ Tenderness
□ Throbbing
□ Ulcers
□ Varicose Veins
□ Spider Veins
□ Skin discoloration
□ Other:
WHERE ARE YOUR SYMPTOMS LOCATED? (check one)
□ Whole Leg
□ Thigh
□ Knee
□ Calf
□ Ankle
□ Buttocks
□ Groin
□ Other:
HOW LONG HAVE YOUR SYMPTOMS BEEN BOTHERING YOU? (fill in a number)
weeks
months
DO YOU HAVE ULCERS?
YES
years
NO
WHICH LEG?
RIGHT
IF YES, HOW LONG HAVE YOU HAD THEM?
RIGHT LEG:
□
days
□
months
□
years
□ N/A
LEFT LEG:
□
days
□
months
□
years
□ N/A
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LEFT
_
WHEN DO YOUR SYMPTOMS OCCUR? CHOOSE THE BEST ANSWER BELOW. (check one)
□ Mostly at nighttime
□ All day
□ Only during the day
□ While laying down
□ At bedtime
□ Other:
ARE YOUR SYMPTOMS WORSE IN ONE LEG THAN THE OTHER? (check one)
□ Worse in the right leg
□ Worse in the left leg
□ Equal in both legs
DO YOUR SYMPTOMS AFFECT YOUR ACTIVITIES OF DAILY LIVING? Yes or No
If yes, which activities are affected: (check all that apply)
□ Exercise
□ Unable to stand Long
□ Unable to walk hills
□ Unable to sit long
□ Walking
□ Unable to work
□ Other:
□ Homemaking
□ Sleep / Relaxation
ARE YOUR SYMPTOMS WORSENED BY: (check all that apply)
□ Prolonged Standing
□ Prolonged Sitting
□ Other:
□ Walking
□ Exercise
□ Heat
□ Premenstrual
□ Hot Bath □ Pregnancy
□ Travel
□ Resting
□ Working
PLEASE MARK ANY CONSERVATIVE THERAPY MEASURES THAT YOU HAVE TRIED IN THE PAST TO RELIEVE
YOUR SYMPTOMS: (check all that apply)
□ Compression stockings □ Weight reduction
□ Cold soak
□ Walking
□ Leg elevation
□ Avoid prolonged sitting
□ Warm soak □ Pain medications
□ Exercise
□ Avoid prolonged standing
□ Other:
If yes to compression stockings:
Compression
How Long?
Length
□ Store bought
weeks
□ Knee High
□ 20 - 30 mm Hg
□ 30 - 40 mm Hg
months
years
□ Thigh High
Worn When?
□ Exercising
□ Night Only
□ All Day
□ Traveling
□ Working
□ Prior EVLA
□ Prior Sclero
□ Prior Surgery
If yes to pain medications: (check all that apply)
□ Rx Meds (include in medication list) □ Naproxen(Aleve)
□ Acetaminophen (Tylenol)
□ Aspirin
□ Ibuprofen (Advil/Motrin)
HOW OFTEN HAVE YOU USED MEDICATION? (check all that apply)
□ Hourly
□ Daily
□ Weekly
□ Monthly
□ 0-2 days/wk
□ 3-4 days/wk
□ 5-6 days in 2 wk period
□ 7 > days in 2 wk period
WAS THERE RELIEF FROM SYMPTOMS WITH THE ABOVE CONSERVATIVE THERAPY MEASURES?
□ Yes
□ No
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HAVE YOU HAD ANY VEIN TREATMENTS PERFORMED IN THE PAST?
Yes or No
If yes, please list them below:
Previous Treatments:
Location:
Side:
Year
Doctor
□ Endovenous Ablation
Front / Back
Right /
Left
_______
___________________________
□ Sclerotherapy/Injections
Front / Back
Right /
Left
_______
___________________________
□ Stab Phlebectomy
Front / Back
Right /
Left
_______
___________________________
□ High Flush Ligation/Stripping
Front / Back
Right /
Left
_______
___________________________
□ Treatment for ulcers,
(Circle)
phlebitis, cellulitis or edema
(Circle)
Type: ______________________________________________________
□ Deep vein thrombolysis
Type: ______________________________________________________
□ Deep vein stenting
Type: ______________________________________________________
PAST MEDICAL HISTORY: (check all that apply)
□ Phlebitis
□ Trauma/Injury to Leg
□ Varicose Veins
□ Migraine Headaches
□ Spider Veins
□ Asthma
□ Bleeding Veins
□ Blood born infectious
disease
□ Leg Ulcers
□ Arrhythmia
□ Leg Swelling/Edema
□ Blood Clots
□ Arterial Disease/Blockage
□ Currently Pregnant/Planning
□ Bleeding Disorder
□ CVA/Stroke
□ Hypertension
□ Heart Problems
□ HIV/AIDS
□ Arthritis
□ Muscular Disease
□ Hormonal Therapy
□ Diabetes
□ Seizures
□ Cancer:
____________________
□ Inability to donate blood
□ Hepatitis
□ Liver Disease
□ Kidney Disease
□ Hyper/Hypothyroidism
□ Other:
_________________________________________________________________________________
PAST SURGICAL HISTORY: (check all that apply)
□ Adenoidectomy
□ Lung Resection
□ Colon Resection
□ Hernia Repair
□ Appendectomy
□ Gall Bladder
□ C-Section
□ Bypass
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□ Prostate
□ Hysterectomy
□ Tubal Ligation
□ Other:
□ Breast Biopsy/Mastectomy
□ Hip Replacement
□ Knee Replacement
□ Thyroid Surgery
□ Tubal Ligation
□ Skin Cancer
□ Breast
Augmentation
□ Tummy Tuck
□ Liposuction
□ Face Lift
____________________________________________________________
Any surgical complications?
___________________________________________________________________
FAMILY HISTORY OF VARICOSE VEINS? Yes or No
If yes, which family members: (check all that apply)
□ Mother
□ Father
□ Siblings
□ Grandmother
FAMILY HISTORY OF CLOTTING DISORDER? Yes or No
If yes, which family members: (check all that apply)
□ Mother
□ Father
SMOKING STATUS:
□ Current every day smoker
□ Siblings
□ Grandmother
□ Current some day smoker □
□ Grandfather
□ Grandfather
Former smoker
□
Never smoked
If you are a current or former smoker, how many packs per day?
How long did you smoke regularly?
years
At what age did you start smoking?
years
HOW MANY PREGNANCIES HAVE YOU HAD?
(number)
HOW MANY CHILDREN DO YOU HAVE? _____ (number)
PLEASE LIST ALL ALLERGIES:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: (including Herbs, Vitamins, Supplements, etc.)
NAME OF MEDICATION
DOSE/FREQUENCY
REASON YOU ARE TAKING
PLEASE MARK ANY ADDITIONAL SYMPTOMS YOU ARE EXPERIENCING TODAY OR RECENTLY:
□ Fatigue
□ Hemorrhoids
□ Anxiety
□ Fever
□ Indigestion
□ Depression
□ Recent Weight Loss
□ Jaundice
□ Insomnia
□ Recent Weight Gain
□ Rectal Bleeding
□ Blood in Urine
□ Disturbance of Vision
□ Vomiting of Blood
□ Irregular Periods
□ Loss of Vision
□ Joint Pain
□ Pain/Burn Urination
□ Chest Pain
□ Leg Cramps
□ Pain w/Menstruation
□ Palpitations
□ Easy Skin Bruising
□ Pelvic Pain
□ Shortness of Breath with activity □ Hair Loss
□ Vulvar/Vaginal Veins
□ Shortness of Breath at rest
□ Skin Itching
□ Cold Intolerance
□ Swelling of Legs & Ankles
□ Skin Rashes
□ Excessive Thirst
□ Cold Sores
□ Skin Lesions
□ Excessive Urination
□ Hoarse Voice
□ Ulcers
□ Heat Intolerance
□ Sinus Problems
□ Difficulty Speaking
□ Incontinence
□ Sore Throat
□ Abnormal Numbness
□ Fainting Spells
□ Chronic/Frequent Cough
□ Dizziness
□ Recurring Infections
□ Cough/Spit Up Blood
□ Drooping of the Face
□ Difficulty Speaking
□ Wheezing
□ Frequent Headaches
□ Abnormal Numbness
□ Abdominal Pain
□ Fainting Spells
□ Dizziness
□ Black Tarry Stools
□ Drooping of the Face
□ Frequent Headaches
□ Difficulties/Painful Swallowing
□ Fainting Spells
□ Fainting Spells
□ Heartburn
□ Heartburn
□ Leg Weakness
□ Nervousness
□ Other: ______________________________________________
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By signing below, I acknowledge that the information I have provided is correct to the best of my ability.
Patient Signature:
Date:
/
/
ACKNOWLEDGEMENT AND CONSENT
INSURANCE AUTHORIZATION: I permit International Vein Centers (IVC) and The Vascular Experts (TVE) to release any
information acquired throughout the course of my examination and treatment as needed to process any claims on my behalf. I
further agree to pay any and all co-pays,deductibles,amount over UCR, and/or excluded charges, exceeding payments
from insurances with whom IVC or TVE does not accept assignment and/or any and all co-pays and deductibles with those
they do accept.
PAYMENT AUTHORIZATION: I request my insurance carrier to pay on my behalf insurance benefits to IVC/TVE for services
rendered. I understand this authorization will be effective until revoked in writing. I understand that if necessary,a credit
bureau report may be obtained. IVC/TVE cannot be held responsible for collecting my insurance claim(s) nor for
negotiating a settlement(s) on a disputed claim(s). IVC/TVE fees are not established by insurance companies.I am
responsible for my account.
HIPAA: In accordance with HIPAA regulations, I acknowledge I have been advised by IVC/TVE privacy policy. I permit
IVC/TVE to send me information via mail, email, or by calling the phone number(s) I have authorized above, regarding my
account, treatment, appointments.
I hereby acknowledge and consent to the above listed policies and procedures of IVC/TVE and understand that this
authorization is valid until revoked in writing.
Patient Signature:
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Date:
/
/
PATIENT NAME:________________________________________
Patient Acknowledgement and Financial Authorization
Authorization for Payment/Financial Agreement
I agree to pay International Vein Clinics (IVC) and The Vascular Experts of Southern Connecticut
Vascular Center (TVE) for all services provided to me, and for any other applicable charges.
I authorize and direct my insurance carrier to make payment to IVC/TVE of all insurance
benefits. I agree to pay any remaining balance not covered by my insurance plan. If I
receive payment from my insurance company or other third party payor for services
provided to me by IVC/TVE, I agree to submit the payment to IVC/TVE. If my bill is not
paid in full, IVC/TVE reserve the right not to provide any future non-emergency medical
services to me.
Disclosures to Family Members, Friends and Personal Representatives
I understand that HIPAA allows me to name a family member(s), friend or any other person I
identify as someone to whom IVC/TVE may disclose my personal health information. I understand
that such disclosures shall be limited to the health information that is directly relevant to the named
person’s involvement with my healthcare or payment for my healthcare. I also understand that
IVC/TVE will follow stringently the guidelines set forth by HIPAA under the policies and
procedures as outlined in the “Disclosures to Family Members, Friends and Personal
Representatives” guidelines and that if I request one, IVC/TVE will provide me with a copy of these
guidelines for reference purposes.
Communications via Cellular Phone and/or Email
If you have provided a cellular telephone number and/or email address as a primary contact
method. I hereby authorize, IVC/TVE, along with respective employees, agents and business
associates, to contact me via cellular phone, text message or email for any reason. Including,
without limitation, feedback surveys, automated notifications, appointment reminders, health
wellness and prevention opportunities. Debt collection agencies may engage, to place calls to your
designated cellular or residential phone, the use of any type of artificial or pre-recorded voice or
auto-dialer technologies for any purpose permitted by law.
Please Sign:
___________________________________________________________________
Date
ULTRASOUND PREPARATION
The staff of International Vein Clinics and The Vascular Experts are dedicated to providing the best possible
therapy for varicose and spider veins. We are one of very few groups in the U.S. which specialize entirely in
“phlebology”, or the exclusive diagnosis and treatment of leg veins. Our main goal of treatment is to provide the
maximum symptomatic and cosmetic improvement for our patients, both short-term and long-term.
In order to provide this treatment in the most effective manner, we need to understand the specific vein
anatomy of each patient prior to treatment. The vein anatomy can differ significantly from one patient to
another, and it is very important for us to know how the largest veins under the surface are functioning prior to
performing treatment. With the improvements in ultrasound technology over the past decade, we have found
that this test (conveniently performed in the office) can accurately provide us with all of this important
information.
When an ultrasound is performed, there are two main aspects of the anatomy that we are evaluating:
1. Patency of the deep veins – this means that the blood is flowing appropriately through these important
veins, and that there are no blockages or blood clots anywhere in the system. It is vital to know this to
assure the patient’s safety when performing treatment.
2. Vascular function – there are millions of veins in the legs, each of which has a small valve or series of
valves to assist the blood in flowing back to the heart (going against gravity). Ultrasound allows us to
evaluate the valve in the largest veins, to see if any of them are incompetent or “leaky”. Leaky valves are
generally the “root of the problem” for varicose veins and many spider veins, and evaluating these prior to
treatment may alter how we approach the treatment of the veins. This helps us to achieve the best
possible long-term results after treatment.
For these reasons, all patients at International Vein Clinics will be required to have an ultrasound scan prior to
beginning or continuing their treatments. We feel that a thorough evaluation of each patient will allow us to
continue providing the best quality and the safest care available for your unwanted leg veins.
HOW TO PREPARE FOR YOUR ULTRASOUND:
On the day of your ultrasound appointment, please follow these instructions:
 Drink at least 3 glasses of water one (1) hour prior to your appointment. Do not drink coffee.
 Eat a meal prior to your appointment.
 Try to be on your feet/walking for at least 20 minutes prior to your appointment.
 Do not apply lotion or oils on your legs.
 Do not wear compression hose/stocking the day of your ultrasound.
 Bring loose fitting shorts to the exam.
APPOINTMENT DURATION



The initial ultrasound appointment will take approximately one hour.
EVLA mappings and follow up exams are approximately 20-30 minutes per leg.
Discussion of your ultrasound with the provider may follow your scan the same day or on a following
visit. This may take 20-30 minutes. If your follow-up visit is scheduled with the provider on the same
day, your appointment will be approximately 1 ½ to 2 hours.
Please keep your appointment. Rescheduled appointments for ultrasounds may delay your treatment
for 60-90 days.
For any questions or concerns relating to your treatment at International Vein Clinics or The Vascular Experts,
please contact your local International Vein Clinics office.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW THE FOLLOWING POLICY CAREFULLY.
IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT THIS NOTICE PLEASE CONTACT OUR PATIENT PRIVACY CONTACT, JODI
DEPALMA, AT OUR ADMINISTRATIVE OFFICES (203) 956-6835.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health
care operations 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 or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The notice will be
effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy
Practices. A copy can be requested in the office at the time of your appointment or a copy can be mailed to your home by calling our office at 1-860886-1949. A current copy of our Notice of Privacy Practices is displayed openly in the waiting room of each of our office locations for patient review.
I.
Uses and Disclosures of Protected Health Information
A. Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by your physician to sign a consent form. Once you have consented to the use and disclosure of your protected health information for
treatment, payment and health care operations by signing the consent form, your physician will use or disclose your protected health information as
described in this Section I of the Notice of Privacy Practices. 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. Your protected
health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice.
The following are examples of the types of uses and disclosures of your protected health information that the physician’s office is permitted to make once
you have signed our consent form.
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 that has already obtained your permission to have access
to your protected health information. For example, we may disclose protected health information to other physicians, such as your primary care
physician, with your permission to help insure that you receive adequate care to treat or diagnose other health issues that they may be treating you for.
In addition, we may disclose your protected health information to another physician or health care provider (e.g. a specialist or laboratory) who, at our
physician’s request, may provide assistance in diagnosing or treating your condition.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain
activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as making
a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization
review activities. For example, pre-approval may be needed for treatment which may require that your relevant protected health information be
disclosed to the health plan to obtain the prior approval needed for treatment.
Healthcare Operations: We may disclose, as needed, your protected health information in order to support the daily business activities of
the physician’s practice. For example, we may ask you to sign-in at the reception desk and we may call you by name in the waiting room when the
physician is ready to see you. However, our common practice is to be as discreet as possible, taking every precaution to insure the privacy of our
patients. We may also disclose your personal health information, with your permission, to contact you at the telephone numbers/address you specify on
the consent, to remind you of appointments, notify you of specials or advise you that an appointment needs to be cancelled and/or rescheduled.
We will share your protected health information with third party “business associates” that perform various activities (e.g. billing, transcription services)
for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health
information, we will have a written contract with that business associate that contains terms that will protect the privacy of your protected health
information.
Any other uses and disclosures of your protected health information, other than those listed above, will be made only with your written authorization,
unless otherwise permitted or required by law as described below. You may revoke this 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.
You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. We may use and disclose your
protected health information in the following instances. If you are not present or able to agree or object to the use or dis closure of the protected health
information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the
protected health information that is relevant to your health care will be disclosed.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, or any other person you identify, your
protected health information that directly relates to that person’s involvement in your health care. 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 protected health information to notify or assist in notifying a family member, personal representative or any person responsible for your
care of your location, general condition and any information that is in the best interest of caring for you as a patient.
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Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, your
physician shall try to obtain your consent as soon as reasonably possible after the treatment. If your physician has attempted to obtain your consent to
disclose your protected health information yet is unable to obtain consent, then he or she may disclose your personal health information to another
physician or any emergency personnel involved in your treatment.
Communication Barriers: We may use and disclose your protected health information if your physician or another physician in the practice
attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional
judgment, that you intend to consent to use or disclose under the circumstance.
B. Other Permitted and Required Uses and Disclosures that may be made without your Consent, Authorization or Opportunity to
Object
We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:
Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The
use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by
law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is
permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also
disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public
health authority.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been
exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits,
investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system,
government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information if we suspect you have been a victim of abuse, neglect or domestic
violence to the government entity or agency authorized to receive such information. In this case the disclosure will be made consistent with the
requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug
Administration to report adverse events, product defects or problems, biologic product deviations, track products, to enable product recalls, to make
repairs or replacements, or to conduct post marketing surveillance as required.
Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a
subpoena, discovery request or other lawful process.
Law Enforcement: We may also disclose protected health information, as long as applicable legal requirements are met, for law enforcement
purposes. These law enforcement purposes include: (1) legal processes and otherwise required by law, (2) limited information requests for identification
and location purposes, (3) pertaining to victims of crime, (4) suspicion that death has occurred as a result of a criminal conduct, (5) in the event that a
crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for
identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also
disclose protected health information to a funeral director and for the purpose of organ donation, as authorized by law, if it is determined that the
protected health information we hold could be pertinent.
Research: We may disclose your protected health information to researchers when their research has been approved by an institutional
review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the
use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose
protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of
individuals who are Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a
determination by the Department of Veteran Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign
military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence
activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and
other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and our physician created or
received your protected health information in the course of providing care to you.
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Required Uses and Disclosures: Under the law, we must make disclosures to you and, when required, the Secretary of the Department of
Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.
II.
Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means that you may inspect and obtain a copy of
protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A
“designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about
you.
Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of,
or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to
have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means that you have the right to 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 a restriction that you may request. If the physician believes it is in your best interest to permit use and
disclosure of your protected health information, then it will not be restricted. If your physician does agree to the requested restriction, we may not use or
disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please
discuss any restriction you wish to request with your physician. You may request a restriction by submitting your detailed request in writing and giving it
to the office where you are being treated or mailing it to the Privacy Contact at the Administrative Service Office at 495 Hawley Lane, Stratford CT
06614. Our physicians reserve the right to refuse treatment if you restrict or deny disclosure of your protected health information.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We
will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or
specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please
make this request in writing and give it to the office where you are being treated or mailing it to the Privacy Contact at the Administrative Service Office at
495 Hawley Lane, Stratford CT 06614.
You may have the right to have your physician amend your protected health information. This means that you may request an
amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may
deny your request for an amendment. 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. Please contact our Privacy Contact if you have questions
about amending your medical records.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This
right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It
excludes disclosures we may have made to you, to a family member or friend who may be involved in your care, or for notification purposes. You have
the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may also request a shorter timeframe. The
right to receive this information is subject to certain exceptions, restrictions and limitations.
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
electronically.
III.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe that your privacy rights have been violated by us. You may file
a complaint with us by notifying our Privacy Contact. We will not retaliate against you for filing a complaint.
You may contact our Privacy Contact, Jodi DePalma, by phone at (203) 956-6835, in writing by mail at 495 Hawley Lane, Stratford CT 06614 or by email
at [email protected] for further information about the complaint process.
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