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PRE-DISQUALIFIERS FOR SURGERY: BMI higher than 32 (CANNOT schedule consult if BMI is higher than 32). Diabetes (Uncontrolled). Sleep Apnea. AFIB. Reynaud's. Factor 5 Blood Disorder. Sickel Cell Anemia or Trait. Malignant Hyperthermia. History Deep Vein Thrombosis (DVT). History Pulmonary Embolism (PE).
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Privacy Compliance Notification
We want you to know we take the protection of your Personal Health Information (PHI) very seriously. We want you to know all of our employees; managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule”. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate uses of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problems of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help up prevent any inappropriate use of PHI and we welcome your input regarding any service problems, so that we may remedy the situation promptly.
Patient Consent Form
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain patients’ consents for uses and disclosures of health information about the patient to carryout treatment, payment, or health care operations.
As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or healthcare operations, in order to provide health care that is in your best interest.
We also want you to know that we support full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entitles are most often not required to obtain patient consent.
You may refuse to consent to the use of disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
Unsecure Communication Policy
Dr. Brandy and his staff are happy to communicate with you via email/text/virtual platforms (such as FaceTime) when you have questions or concerns. If you initiate email/text/virtual platforms for communication rather than the alternative of talking to Dr. Brandy and/or his staff by phone or in person, you accept the risks of using such unsecure methods, which could result in the interception of protected health information (PHI) by unaffiliated parties. By signing below, you are stating that you’ve been notified of the risks, benefits and alternatives of the use of email/text/virtual platforms for communication with Dr. Brandy and/or his staff, you accept the responsibilities and/or consequences that may arise from such communication, and you agree to hold Dr. Brandy and his staff harmless should such an interception occur.