CONTACT APPOINTMENTS DIRECTIONS

New Patient Registration Form

New Patient Registration Form

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Local Pharmacy Information

Mail Order Pharmacy Information

PATIENT INFORMATION

INSURANCE INFORMATION

REFERRAL INFORMATION

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DEMOGRAPHICS & HOUSEHOLD

CURRENT MEDICATIONS

(No need to rewrite medications below.)

Please list all medications that you are currently taking including prescriptions, over the counter (Advil, Tylenol, Motrin, Aleve, etc.), vitamins, supplements, home remedies, birth control pills, inhalers and sprays.

Please list any medications you are allergic to and describe the reaction.

ALLERGIES & IMMUNIZATIONS

Please check all immunizations that you've received and write in the year if known.

HOSPITALIZATIONS & INTERVENTIONS

Please list any past surgeries and include the year and facility/location.

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HOSPITALIZATIONS & INTERVENTIONS

Please list any past surgeries and include the year and facility/location.

Please list any past diagnostic exams or medical procedures you have had and include the year and findings/outcome.

PATIENT HEALTH HISTORY

Please check any of the following conditions that apply to you.

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FAMILY HISTORY

Please complete the following as it relates to your immediate biological family including parents, grandparents, siblings, and children.

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SOCIAL HISTORY

Exercise

Caffeine

Alcohol

Tobacco

Drugs

Sex

Mental Health

Safety

WOMEN ONLY

MEN ONLY

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OTHER INFORMATION

(Advance directives are written, legal instructions regarding your preferences for medical care if you become unable to make medical decisions for yourself.)

INFORMATION REVIEW

I have reviewed the information provided above and acknowledge that the information provided is true, accurate, and complete to the best of my ability.

Use your mouse or finger to sign in the box below.

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ADVANCE DIRECTIVE

I, the above-named patient, being of sound mind, declare this to be my advance directive.

APPOINTMENT OF HEALTHCARE PROXY

I appoint the following individual to make healthcare decisions on my behalf if I am unable to do so:

HEALTHCARE INSTRUCTIONS

PHYSICIANS ORDERS


I understand that I may also have the option to execute a separate Physician's Orders for Life Sustaining Treatment (POLST) form, which will provide specific medical orders for my care. I have been informed about the Physician's Orders form, and my physician has explained its purpose and use to me.


EFFECTIVE DATE


This advance directive is effective immediately and will remain in effect until I revoke it.


REVOCATION


I reserve the right to revoke this advance directive at any time. I understand that revocation must be in writing and delivered to my healthcare agent.


I understand the contents of this advance directive form and I have had the opportunity to ask questions and receive answers about it. I have executed this document on my own free will.

Use your mouse or finger to sign in the box below.

Use your mouse or finger to sign in the box below.

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CONSENT TO MEDICAL TREATMENT

I, the above-named patient, hereby give my informed consent to [Nabila Aslam M.D./ Internists of North Dallas PA] and any other healthcare providers who may be involved in my care to provide medical treatment, examinations, procedures, and diagnostic tests as deemed necessary for my health condition.


• I understand that the purpose of this medical treatment is to address and manage my health condition, and that there may be alternative treatments or procedures available that have not been recommended to me.

• I understand that the healthcare providers involved in my care may need to disclose my protected health information to other healthcare providers involved in my treatment, for the purpose of coordinating my care.

• I understand that the healthcare providers will make every effort to maintain the confidentiality of my protected health information, but that there may be certain situations where disclosure may be required by law, such as reporting of communicable diseases or suspected child abuse.

• I have had the opportunity to ask questions about the proposed treatment, and my questions have been answered to my satisfaction. I have been given a reasonable explanation of the risks, benefits, and alternatives to the proposed treatment, and I understand the potential consequences of refusing treatment.

• I understand that I have the right to revoke this consent at any time, except to the extent that action has been taken in reliance on it.


I certify that I have read and fully understand the above information, and that I have had an opportunity to ask questions about the proposed treatment. I voluntarily consent to receive medical treatment, examinations, procedures, and diagnostic tests as deemed necessary by my healthcare providers.

Use your mouse or finger to sign in the box below.

Use your mouse or finger to sign in the box below.

FINANCIAL RESPONSIBILITY AGREEMENT

I, the above-named patient, understand that I am financially responsible for all services provided to me by [Nabila Aslam M.D./ Internists of North Dallas PA]


• I agree to pay for all services provided to me by the healthcare provider or clinic at the time services are rendered.

• I agree to provide accurate and complete insurance information and to notify the healthcare provider or clinic of any changes in my insurance coverage. I understand that I am responsible for any amounts not covered by my insurance plan.

• I acknowledge that I am responsible for paying any co-payments, deductibles, or other out-of-pocket expenses at the time of service. If I am unable to pay for the services provided, I agree to make payment arrangements with the healthcare provider or clinic.

• I authorize the healthcare provider or clinic to release any necessary information to my insurance company or any other party responsible for payment of my healthcare services.

• I agree to provide the healthcare provider or clinic with updated contact information, including my mailing address, phone number, and email address.

• I understand that failure to pay for services provided may result in the healthcare provider or clinic taking legal action to collect payment, and that I may be responsible for any legal fees and expenses incurred by the healthcare provider or clinic in such an action.


By signing below, I acknowledge that I have read and understand the financial responsibility agreement and agree to comply with its terms.

Use your mouse or finger to sign in the box below.

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HEALTH INFORMATION EXCHANGE CONSENT

I, the above-named patient, hereby authorize the electronic exchange of my protected health information (PHI) through the Health Information Exchange (HIE) network.


I understand that the purpose of the HIE is to improve the quality, safety, and efficiency of my healthcare by allowing my healthcare providers to securely access and share my PHI with each other. I understand that the information exchanged may include, but is not limited to, the following:


• Medical history and diagnoses

• Medications and allergies

• Lab and test results

• Imaging reports

• Discharge summaries

• Treatment plans and progress notes


I understand that my PHI will only be exchanged between healthcare providers who are involved in my care and who have a legitimate need for the information. I understand that my PHI will be protected by state and federal laws governing the privacy and security of health information.


I have the right to revoke this consent at any time by notifying the HIE in writing. I understand that if I revoke this consent, it will not affect any actions taken prior to the revocation.


I have received a copy of the Notice of Privacy Practices, which explains in detail how my PHI may be used and disclosed, and I understand my rights and responsibilities with respect to my PHI.


By signing below, I acknowledge that I have read this consent form, understand its contents, and agree to the electronic exchange of my PHI through the HIE network.

Use your mouse or finger to sign in the box below.

Use your mouse or finger to sign in the box below.

HIPAA CONSENT

I understand and acknowledge that [Internists of North Dallas PA] is committed to safeguarding the privacy and security of my protected health information (PHI) as required by the Health Insurance Portability and Accountability Act (HIPAA) and its associated regulations.

1. Authorization for Use and Disclosure of PHI: I authorize [Internists of North Dallas PA] to use and disclose my PHI for the purpose of treatment, payment, and healthcare operations. This includes but is not limited to sharing information with other healthcare providers involved in my care, insurance companies for claims processing, and necessary administrative and billing purposes.

2. Rights Regarding My PHI: I understand that I have the right to:

  • a. Request restrictions on certain uses and disclosures of my PHI, although [Internists of North Dallas PA] may not be obligated to comply with such requests.
  • b. Access, inspect, and obtain copies of my medical records, subject to legal limitations and any associated fees.
  • c. Request amendments or corrections to my medical records if I believe they are inaccurate or incomplete.
  • d. Receive an accounting of disclosures made of my PHI by [Internists of North Dallas PA] for purposes other than treatment, payment, or healthcare operations.
  • e. Request confidential communications, such as alternative methods or locations, to receive communications of my PHI.


3. Authorization Revocation: I understand that I have the right to revoke this HIPAA consent at any time. However, such revocation will not affect any actions taken by [Internists of North Dallas PA] prior to receiving the revocation.

4. Acknowledgment of Privacy Notice: I have received a copy of the Notice of Privacy Practices from [Internists of North Dallas PA] , which explains in detail how my PHI may be used and disclosed and outlines my rights as a patient under HIPAA.

I acknowledge that I have read and understood the above information and voluntarily provide my consent for [Internists of North Dallas PA] to use and disclose my PHI as outlined in this HIPAA Consent Form.

Use your mouse or finger to sign in the box below.

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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 it carefully.


OUR OBLIGATIONS

We are committed to maintaining the privacy of your medical information. We are required by law to maintain the privacy of your medical information and to provide you with this notice of our privacy practices.


USES AND DISCLOSURES OF MEDICAL INFORMATION

We may use and disclose your medical information for treatment, payment, and healthcare operations purposes. We may also use and disclose your medical information for other purposes that are permitted or required by law, such as for public health activities or in response to a court order.


YOUR RIGHTS

You have the right to access and receive a copy of your medical information, request amendments to your medical information, and receive an accounting of certain disclosures of your medical information. You also have the right to request that we communicate with you about your medical information in a certain way or at a certain location.


OUR CONTACT INFORMATION

If you have any questions or concerns about this notice or our privacy practices, please contact our privacy officer at the address and phone number listed below:


[Internists of North Dallas PA]

[4500 North MacArthur Blvd; Suite 130, Irving, TX 75038]

[469-690-2208]

EFFECTIVE DATE

RELEASE OF INFORMATION

ENTITY TO RELEASE INFORMATION

I authorize the following information to be released from my medical record:

ENTITY TO RECEIVE INFORMATION

*If patient is the recipient, write "self" for Entity Name and complete the information needed to complete the transfer.

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RELEASE OF INFORMATION

I, the above-named patient, authorize the entity named to release or disclose my health information, which may include information related to psychiatric impairment, drug abuse, alcoholism, sickle cell anemia, sexually transmitted disease, Acquired Immunodeficiency Syndrome (AIDS), or tests for/infection with Human Immunodeficiency Virus (HIV).

Use your mouse or finger to sign in the box below.

Use your mouse or finger to sign in the box below.

VERBAL AUTHORIZATION (for patients physically or cognitively unable to sign)

Use your mouse or finger to sign in the box below.

Use your mouse or finger to sign in the box below.

HIPAA

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