● I also understand that it is my responsibility to present a valid referral at each visit. This Office will not call for the referral. If a valid referral is not available at the time of visit, then I agree to reschedule the appointment.
● I understand and agree that results of blood tests, etc. will not be discussed over the phone. You must schedule an appointment to discuss the results with the doctor.
● I agree that the primary purpose of the Appointment system is to form an orderly queue. By giving me an appointment time, I am placed in this queue, and depending upon how fast or how slow the queue flows, I might be seen either earlier or later relative to my designated appointment time. Even though this office makes its best effort to manage this queue well so that each patient is seen close to his/her appointment time, I understand that delays may still occur relative to my assigned appointment. Moreover, I also understand that this queue may be have to be modified on rare occasions to attend to patients in need of urgent / emergency care.
● I agree that this is a specialist office, and therefore this office will not be signing FORMS that are more appropriately meant to be signed by my PCP (Primary Care Physician) or by the referring physician.
● Not paying my deductible(s) or other dues will lead to automatic termination from the practice and my delinquent account will be turned over to our collection attorneys for legal action.
● I am responsible for taking care of my belongings. The office is not responsible for your lost or damaged item.
● I agree to abide by all office guidelines including maintaining a peaceful behavior/demeanor during my visit to the office. Rude and arrogant behavior is not permitted. And, I understand that any kind of THREATENING or PROVOCATIVE language/behavior directed at the office personnel, either in the office or over the phone, or by any other means, will not be tolerated, and will automatically lead to my termination from the practice, and I could be subjected to other disciplinary action as well.
Notice of Privacy Practices
● I have received this practice’s Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice’s legal duties with respect to my protected health information. The Notice includes:
● A statement that this practice is required by law to maintain the privacy of protected health information.
● A statement that this practice is required to abide by the terms of the notice currently in effect
● Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
● A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization
● A description of uses and disclosures that are prohibited or materially limited by law
● A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
• The right to complain to this practice and to the secretary of HHS if I believe my privacy rights have been violated, and that no
retaliatory actions will be used against me in the event of such complaint.
• The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not
required to agree to a requested restriction
• The right to receive confidential communications of protected health Information
• The right to inspect and copy protected health information
• The right to amend protected health information
• The right to receive an accounting of disclosures of protected health information
This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices on request
Consent for Routine Diagnosis and Treatment
I have come to Fauzia Syed-Khan, MD to voluntarily seek medical services which may include routine diagnostic and treatment procedures, provided by her or by the staff in her office. I fully understand that the results of the services I will receive is/are not guaranteed. Furthermore, I acknowledge that this consent will remain valid until I explicitly revoke it. This consent will govern the performance of routine diagnostic and treatment procedures such as blood drawing, external physical exam, and other routine non-invasive procedures.
