Notice of Privacy Practices

Full text

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Revised 11/05

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed, and how you may

obtain access to this information. Please review it carefully.

OMAC respects your privacy. We understand that your personal health information is very sensitive. We will

not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us

to do so.

The law protects the privacy of the health information we create and obtain in our medical evaluation. For

example, your protected health information (PHI) includes your symptoms, test results, diagnoses, treatment,

health information from other providers, and billing and payment information relating to these services.

Federal and state law allows us to use and disclose your protected health information for purposes of

evaluation, treatment and health care operations. State law requires us to get your authorization to disclose

this information for payment purposes.

Examples of use and disclosures of PHI for treatment and payment

For evaluation:

 Information obtained by a physician or other member of our health care team will be recorded in your

medical record and used to provide an evaluation of your current medical condition.

 We may also provide information to others providing your care or to those who are authorized to

have access through the claims process. This will help them stay informed about your care.

For payment:

 Information about services performed will be provided to others by OMAC for billing purposes. This

information may consist of your IME, test results or services performed.

Our responsibilities

We are required to:

 Keep your PHI private

 Give you this notice

 Follow the terms of this notice

We have the right to change our practices regarding the PHI we maintain. If we make changes, we will

update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by

visiting our office to pick one up.

To ask for help or voice a concern

If you have questions, want more information, or want to report a problem about the handling of your PHI,

you may contact:

OMAC

401 Second Avenue South, Suite 110

Seattle, WA 98104.

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Examinee Information (Exam Form)

Personal Information

Name:_______________________________ Gender: M / F Date of Birth:________ Age:__________ Address:_____________________________________ Phone: (_____) _____________________ Inc. City & State

______________________________________ Ht:_____ Wt:____ Dom. Hand: Lt. Rt. # of Dependents:______ Marital Status:________ Military Service:Y N Branch:____________ Highest Level of Education:_____________ Hobbies:______________________________________ Exercise (type & Frequency):____________________________________________________________

Tobacco (Packs/ day):________ Alcohol (Drinks/week):_______ Illicit Drugs:_________________

Please write in N/A if not applicable Please write in N/A if not applicable Please write in N/A if not applicable

Current Medications:__________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Prior Surgeries: ______________________________________________________________________ Allergies:___________________________________________________________________________

Employment Information

Employer at time of injury:___________________________________ Claim #:__________________ Are you currently working? Y N If not why?_________________________________________ List any work related benefits you are receiving (Short term disability, long term disability, employer sponsored Medical,etc.)_______________________________________________________________

__________________________________________________________________________________

Family History

Please list any chronic medical conditions and/or illnesses, which run in your family (diabetes, high blood pressure, heart disease, cancer, etc.).

Mother:__________________________________ Father:___________________________________ __________________________________ ___________________________________

__________________________________ ___________________________________

I UNDERSTAND THAT I AM BEING SEEN FOR AN INDEPENDENT MEDICAL EVALUATION BY THE DOCTOR(S) AND NO TREATING

PHYSICIAN/PATIENT RELATIONSHIP IS ESTABLISHED. I UNDERSTAND THAT THE INFORMATION I DISCUSS WILL BE INCLUDED IN A REPORT THAT IS PREPARED FOR THE REQUESTING CLIENT. I ALSO UNDERSTAND THE EXAMINING PHYSICIAN IS PERMITTED TO PROVIDE THIS REPORT TO THE REQUESTING PARTY. I UNDERSTAND THE DOCTOR WILL NOT DISCUSS THE RESULTS OF MY EVALUATION WITH ME AND WILL NOT RENDER ANY MEDICAL ADVICE OR TREATMENT TO ME. I CONSENT TO THIS REPORT BEING SENT TO THIS CLIENT AND TO PARTICIPATING IN THE ASSESSMENT. I AGREE TO ADVISE THE PHYSICIAN IMMEDIATELY IF I EXPERIENCE ANY DIFFICULTIES DURING THE EXAMINATION.I UNDERSTAND I AM ENTITLED TO A COPY OF THIS REPORT AND MUST OBTAIN IT THROUGH THE REQUESTING CLIENT.THIS EXAMINATION WILL BE KEPT CONFIDENTIAL IN ACCORDANCE WITH ALL APPLICABLE LAWS.

TO BE SIGNED AT THE TIME OF THE EXAM

SIGNED: ___________________________________________DATE:_________________________

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Examinee Medical History

(Review of Systems)

Please Check All That Apply:

Hematologic:

HEENT:

 Glasses or contacts

 Foreign body in eyes

 Weak eyes

 Eye surgery

 Recurrent ear infections

 Sinus or nasal passage problems

 Double vision

 Tear duct problems

 Hearing problems

Cardiovascular:

 Irregular heart beat

 Chest pain

 Night sweats

 Coronary artery disease

 Heart murmur

 High blood pressure

 Varicose veins

Pulmonary:

 Asthma

 Chronic cough

 Unusual shortness of breath

Gastrointestinal:

 Swallowing problems

 Appetite problems

 Digestion problems

 Ulcers

 Heartburn

 Nausea

 Gall bladder problems

 Jaundice

 Vomiting blood

 Rectal bleeding

Genitourinary:

 Kidney disease

 Bowel or bladder problems

 STD

 Urinating difficulty

 Bladder infection

 Anemia/leukemia

 Lymphoma

 Abnormal cell count

 Abnormal platelet count

 Blood thinner use

Dermatologic:

 MRSA

 Eczema

 Psoriasis

 Fungal infection

 Unusual moles

 Skin cancer

 Severe acne

 Tattoos

Endocrinologic:

 Thyroid problems

 Pituitary gland problems

 Adrenal gland problems

 Diabetes

Neuropsychiatric:

 Convulsions

 Anger control problems

 Mental illness

 Sleep problems

 Mood swings

 Anxiety

 Depression

Musculoskeletal:

 Systemic arthritis

 Neck pain

 Back pain

 Joint pain

 Fibromyalgia

List any fractures or broken bones:

 Pelvic inflammatory disease

 Prostate problems

2/18/2011

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401 Second Avenue South  Suite 110  Seattle WA 98104  Telephone: 206.324.6622 Toll Free: 1.800.331.6622  Fax: 206.726.8605  www.omacime.com

Pain Diagram

Using the diagrams below, circle and label the areas where you feel any of the following sensations:

1. Numbness 2. Pins and Needles 3. Burning Pain 4. Stabbing Pain 5. Aching Pain

If the sensation is spreading to other areas, use arrows to indicate where and in which direction. Please fill this out as carefully as possible, as it helps the physician to better understand where and how you are hurting.

Please briefly describe your injury;

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Medical Records Release/Notification of Privacy Rights

I understand that by refusing to complete this form Objective Medical Assessment Corporation may be unable to produce a complete Independent Medical Exam report regarding my claim.

Examinee Name: ____________________________________________ (Print)

Limitations on the information subject to this Release Form are as follows: Limited to Area of Injury:

(please list injured body part(s)

Release my protected health information to the following entity:

Objective Medical Assessments Corporation 401 Second Avenue South, Suite 110

Seattle, WA 98104

The reasons for this release of information are as follows (check one):

 Worker’s compensation medical examination  Auto accident/casualty medical examination  Crime victim/personal injury medical examination

By my signature below I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my

protected health information, to the entity listed above.

_________________________________________________ ___________ Examinee signature (his or her parent and or legal guardian) Date

Acknowledgment of privacy practices: In conjunction with the claims manager and/or caretaker assigned

to your case, we keep a record of the health care services we provide you. By contacting your claims manager or his or her medical or legal representative, you may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to persons or parties other than your claims manager and/or his or her medical or legal representative, unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting your claims manager and/or his or her medical or legal representative.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access that information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

__________________________________________________ ___________

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References

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