ACKNOWLEDGEMENT OF RIGHT TO REVIEW TAOS ORTHOPAEDIC

INSTITUTE’S NOTICE OF PRIVACY PRACTICES

 

I understand I have a right to review Taos Orthopaedic Institute’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices is available at the reception desk and a copy is available on-line at www.taosortho.com.

 

Taos Orthopaedic Institute reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I understand that I may obtain a revised notice of privacy practices by accessing Taos Orthopaedic Institute’s website, calling the office and requesting a revised copy be sent in the mail, or by requesting a revised copy at the time of my next appointment.

 

                                                                                                                                                                          

Signature of Patient or Personal Representative                                              Date

 

                                                                                                                                                                                   

Print Name of Patient or Personal Representative

 

                                                                                                                                                                                    Description of Personal Representative’s Authority (i.e. Legal guardian, parent, attorney, etc.)

 

 

If you wish to request RESTRICTIONS or limitations on the use of your Protected Health Information, or to request confidential communications please let our receptionist know, so that the proper forms may be completed.  Please indicate below if you would not like us leave account information on your cell phone answering system or your home answering machine.

 

                                                                                                                                                                                   

 

Please list the names and relations of anyone you wish to be involved in your care and payment and with whom we may share your medical information:

 

                                                                                                                                                                                   

 

                                                                                                                                                                                   

 

                                                                                                                                                                                   

 

STATEMENT IN REGARD TO LEGAL CASES AND TESTIMONY

This statement is to acquaint you with our policy in regard to accepting cases with legal involvement or requiring testimony.  Because of our heavy clinical research and teaching responsibilities, and the ongoing requirements regarding patient care, we find it impossible to accept any new patients with legal involvement or cases requiring testimony.  It is essentially impossible to predict which cases with legal involvement will require testimony and which will not.  It has thus been our decision to not accept cases of this nature and we will refer patients who need this type of assistance to other physicians for their care.  A predominant reason for declining participation in cases with legal involvement is that it would potentially mean we would have to deny medical care to other patients.  We feel our primary obligation is to render medical care and treatment rather than testimony and assistance in lawsuits.

I have read the above statement and I agree not to require your participation in legal proceedings.

 

                                                                                                                                                                       

                          Patient Signature                                                                           Date

 

Foy Office Use Only:

 

Acknowledgement of receipt of Notice Of Privacy Practices was unable to be attained because:

                                                                                                                                                                                                                                                                                                                                                                       

Signature of Staff Member:                                                                        Date