Dear Patient:
Thank you for choosing Rheumatology Associates of Baltimore for your rheumatologic care.
We are providing the following information to help you prepare for a smooth visit in our office.
We respect your time and would like to make your visit to our office as satisfying as possible.
Location:
We are located in the Radio Park complex on the north side of Joppa Road, between Goucher
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building facing Joppa Road and is clearly marked with an awning. Ample parking is available at street level.
Medical Information:
Please complete the enclosed Medical Information sheet and bring it with you, as well as a list of all medications you are currently taking. Please bring any medical records, x-rays, films, lab test results or hospital summaries you may have or contact the office with your referring SK\VLFLDQ¶VLQIRUPDWLRQVRZHPD\JDWKHUPHGLFDOUHFRUGVSULRUWR\RXUYLVLW,QRUGHUWRDVVXUH
that your entire appointment time is spent with the physician, please complete ALL paperwork in advance and plan to arrive 15 minutes early.
Health Insurance:
Please bring your current insurance card, pharmacy card, and a photo ID so that we may file for reimbursement on your behalf. Your deductible, co-pay and/or coinsurance remains your personal responsibility and payment is expected at the time of the visit. If you are un-insured, payment is expected in full at the time of the visit unless a payment plan has been pre-
arranged. If you have any questions, please do not hesitate to contact our Billing Manager, Judith Lobus at 443-652-1211.
Please plan to arrive for your office visit at least 15 minutes before your
appointment to allow time for registration. %HFDXVHRIWKHFRPSOH[LW\RIRXUSDWLHQW¶V
medical issues, our physicians and nurse practitioners may find it necessary to take more time WKDQH[SHFWHGWREHVWPHHWDSDWLHQW¶VQHHGV:HDSSUHFLDWH\RXUSDWLHQFHRIWKRVHRFFDVLRQV
when this level of care effects your appointment time. Please be assured that you will be given the same level of care at your appointment.
We look forward to meeting you in person.
Important Message Regarding Confirmation of This
Appointment
If you are unable to keep your appointment, kindly notify us as early as
possible. You will receive a call from the office to confirm your
appointment up to two weeks in advance of the appointment. If we are
unable to reach you and do not hear from you to confirm the
appointment, we may offer the scheduled appointment time to
another patient. Please make certain that we have accurate contact
information and that it is kept up to date in the event of a change.
Date:____________________
To:______________________ Address:_______________________________ Fax:___________
Date release is valid to (maximum period of time is one year):____________
Records to be sent to:
___H. Hauptman, MD ___L. Ludmer, MD ___A. Karhadkar, MD ____T. Rehman MD ____P. Taitt, MD ___R. Marsden,CRNP __P. Lentz CRNP
Address: 1220B. E. Joppa Road Suite 310
Baltimore, Maryland 21286
Please submit the following information in the medical record noted below:
Everything, the complete record.__________
Everything in the record prior to __________
Everything in the record from this time forward___________
Everything in the medical record that relates to the following conditions and/or treatments:
_____________________________________________________________________________________
_____________________________________________________________________________________
This purpose in requesting this information is for:
Consideration of medical treatment for ____________________________________________________
Other________________________________________________________________________________
_____________________________________________________________________________________
I,___________________________________ hereby request that you release my medical record to the above noted location for the reasons noted above.
Patient Name:__________________________ Date of Birth: ______________
Address:______________________________________________________________________________
_____________________________________________________________________________________
Patient Signature ________________________________________ Date ______________
Rheumatology Associates of Baltimore, L L C Notice of Information Practices
Your Rights under the Federal Privacy Standard
Although your health records are the physical property of the health care provider who
completed the records, you have the following rights with regard to the information contained therein:
Request restriction on uses and disclosures of your health information for treatment, payment, and health care operations. Obtain a copy of this notice of information practices.
Although we have posted a copy in prominent locations throughout the facility and on our website, you have a right to a hard copy upon request.
Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such as if access would cause harm, we can deny access. You do not have a right of access to the following:
o Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care provider who is a mental health professional documenting or analyzing a conversation during a private, group, joint, or family counseling session and that are separated from the rest of your medical record.
o Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or proceedings.
o 3URWHFWHGKHDOWKLQIRUPDWLRQ ³3+,´ WKDWLVVXEMHFWWRWKH&OLQLFDO/DERUDWRU\
,PSURYHPHQW$PHQGPHQWVRI ³&/,$´ 86& 263a, to the extent that giving you access would be prohibited by law.
o Information that was obtained from someone other than a health care provider under a promise of confidentiality and the requested access would be reasonably likely to reveal the source of the information.
Request amendment/correction of your health information. We do not have to grant the request if the following conditions exist:
o We did not create the record. If, as in the case of a consultation report from another provider, we did not create the record, we cannot know whether it is accurate or not.
Thus, in such cases, you must seek amendment/correction from the party creating the record. If the party amends or corrects the record, we will put the corrected record into our records.
o The records are not available to you as discussed immediately above.
attach a statement of disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will make the correction and distribute the correction to those who need it and those whom you identify to us that you want to receive the corrected information.
Obtain an accounting of non-routine uses and disclosures, those other than for treatment, payment, and health care operations until a date that the federal Department of Health and Human Services will set after January 1, 2011. After that date, we will have to provide an accounting to you upon request for uses and disclosures for treatment, payment, and health care operations. We do not need to provide an accounting for the following disclosures:
o To you for disclosures of protected health information to you.
o For the facility directory or to persons involved in your care or for other notification purposes as provided in § 164.510 of the federal privacy regulations (uses and
disclosures requiring an opportunity for the individual to agree or to object, including notification to family members, personal representatives, or other persons responsible for your care, of the your location, general condition, or death).
o For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations (disclosures not requiring consent, authorization, or an
opportunity to object).
o To correctional institutions or law enforcement officials under § 164.512(k)(5) of the federal privacy regulations (disclosures not requiring consent, authorization, or an opportunity to object).
o That occurred before April 14, 2003.
We must provide the accounting within 60 days. The accounting must include the following information:
o Date of each disclosure.
o Name and address of the organization or person who received the protected health information.
o Brief description of the information disclosed.
o Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the disclosure or, in lieu of such statement, a copy of your written
authorization or a copy of the written request for disclosure.
The first accounting in any 12-month period is free. Thereafter, we reserve the right to charge a reasonable, cost-based fee.
Revoke your consent or authorization to use or disclose health information except to the extent that we have taken action in reliance on the consent or authorization.
O ur Responsibilities under the Federal Privacy Standard
In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the following measures:
Maintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.
Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.
Abide by the terms of this notice.
Train our personnel concerning privacy and confidentiality.
Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies with regard thereto.
Mitigate (lessen the harm of) any breach of privacy/confidentiality.
We will not use or disclose your health information without your consent or authorization, except as described in this notice or otherwise required by law.
How to Get More Information or to Report a Problem
If you have questions and/or would like additional information, you may contact our Practice Manager, Ann Marslett at 410-494-1888.
Effective date: September 1, 2012
Rheumatology Associates of Baltimore
WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO
MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF WE
CHANGE OUR INFORMATION PRACTICES, WE WILL MAIL A
REVISED NOTICE TO THE ADDRESS THAT YOU HAVE GIVEN US.
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
I ________________________________________ acknowledge the receipt of these policies and consent to their use relevant to the information in my medical record.
Effective Date: 09/01/2012
Signature:________________________________ Date:______________
Print Name: ______________________________
Witness: ______________________________
Patient Information Form
Name:______________________________________ SS#__________________________
Street Address_______________________________________________________________________
City/State/Zip______________________________________________________________________
Home Phone___________________ Work#_____________________ Cell#_____________________
E-Mail Address_______________________________________________________________________
Date of Birth________________ Gender: Male Female Marital Status S M W D Sep
*Race ______________________ Ethnicity_ ___________________ *Smoker? Yes No
*Reporting of race and ethnicity is voluntary;; however, your insurance company and Medicare have asked us to capture and report this information.
Employment Status: Employed Employer Name_______________________________________
Retired Retirement date:________________ Disabled Disability date____________________
Spouse Name: ________________________________ DOB: _________________SS#_____________
6SRXVH·V(PSOR\PHQW6WDWXV Employed Employer Name: ____________________________
Retired Retirement date: ______________ Disabled Disability date______________________
Parent name (if Minor) ______________________________________Work #____________________
Nearest relative/friend to call in case of emergency:
Name: _____________________________ Relationship________________ Phone #______________
Referring Physician ___________________________________ Phone: _______________________
Primary Care Physician:__________________________________ Phone:_______________________
Primary Insurance_________________________ Policy#________________ Group#_____________
_
3ROLF\+ROGHU·V1DPH BBBBBBBBBBBBBBBBBBBBBB______________ Date of Birth:________________
Secondary Insurance________________________ Policy #________________ Group#____________
3ROLF\+ROGHU·V1DPH BBBBBBBBBBBBBBBBBBBBBB____________ Date of Birth:__________________
Please Read: I hereby authorize Rheumatology Associates of Baltimore, LLC to furnish information to my insurance carrier at the time of treatment concerning my illness and treatments and hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. This will remain in effect unless revoked in writing.
Signature of Patient: ___________________________________ Date: __________________
Preferred Pharmacy
Phone: _____________________________
