Patient Employer Information
Employer’s Name :
Responsible Party Other than Patient
Responsible Party Information:
Relationship to Patient:
Primary Care Physician and Referring Physician
Primary Care Physician :
Referring Physician (if different from PCP):
Primary Insurance Name:
Secondary Insurance Name:
Subscriber’s Name :
Have you ever had the following? Please circle all that apply.
Previous Hospitalizations and Surgeries (Please include dates):
Family Medical History
Has anyone in your family had any of the following:
Current Social History (circle)
Tobacco – years of use:
Has smoked since age:
REVIEW OF SYSTEMS
Please circle and describe how you are feeling today
Consent for Release of Information and Test Results
Please check and complete the following:
OK to leave messages/fax:
Welcome to SOUTHWEST KIDNEY INSTITUTE, PLC. We are dedicated to quality healthcare. We have experienced
staff that understands your need for confidentiality and compassion. We are required to have you provide information
to our office in order to file your insurance. Please be sure you have given us the correct insurance card as we will
need to copy both front and back of the card. We also will ask that you provide us with a picture ID for your chart (i.e.
driver’s license, etc.). Co-payments are due at the time of service. We ask that any balance owing be paid promptly.
Please read and sign the following so that we may file your insurance.
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.
Southwest Kidney Institute, PLC (the "Practice") is dedicated to maintaining the privacy of your personal health
information. Each time a patient visits this office; a record is made that describes the treatments and services
provided. Federal law outlines specific privacy protections and individual rights related to the information we maintain
that identifies you as a patient. Protected information includes demographic data and facts about your past, present
or future physical or mental health. Our office has put in place policies and procedures to help protect your health
information. We are required to provide this notice outlining our legal duties and responsibilities related to the use and
disclosure of patient identifiable health information, Privacy Practices, and examples of how your information may be
used or disclosed. Company will abide by the terms of this notice. We may revise this notice at any time. The new
notice will be posted in our office in a prominent location. You can request a copy of our most current notice at any
time. Revisions to the notice will be effective for all health care information this office maintains: past, present or
Company may use your individually identifiable health information for the following purposes without your
Treatment: We may use and disclose your identifiable health information to treat you and assist others in
your treatment. For instance, we may send a copy of your records to another doctor so that you can be
evaluated for a specific condition, or we may disclose information to others who take part in your care,
such as your spouse, children or parents.
Payment: We may use your health information to bill and collect payment for services provided. This may
include providing your insurance company with the details of your treatment, sharing your payment
information with other treatment providers, contacting you over the phone or through the mail about
balances, or sending unpaid balances to a collection agency.
Health Care Operations: We may use and disclose health information to operate our business. For example,
your health information may be used to evaluate the quality of care we provide, for state licensing or to
identify you by name when you visit the office.
Appointment Reminders: We may use and disclose your information to remind you of appointments. We
may also mail you a reminder postcard for follow-up visits.
Treatment Options: We may use your health information to inform you of treatment options or other health related
services which may be of interest to you
Business Associates: We may share your health information with other individuals or companies that
perform various activities for, or on behalf of, our office such as afterhour’s telephone answering, billing or
quality assurance. Our Business Associates agree to protect the privacy of your health information.
Research: We may use your information in conjunction with agents of the Practice who may be required to
review your files, just as our employees are so permitted, in order to determine whether you are qualified
for a research project. If you are asked to join a research project, you will be asked first to execute an
authorization, granting the Practice or a research organization the right to use your protected health
Company may disclose your health information without your authorization when permitted or required to by law,
For public health activities including reporting of certain communicable diseases.
For workers' compensation or similar programs as required by law.
To authorities when we suspect abuse, neglect or domestic violence.
To health oversight agencies.
To your employer if we provide health care services to you at the request of the employer, whereupon we
shall provide you written notice of release so such information.
For certain judicial and administrative proceedings pursuant to an administrative order.
For law enforcement purposes.
To a medical examiner, coroner or funeral director.
For the facilitation of organ, eye or tissue donation if you are an organ donor.
For research purposes under strictly limited circumstances.
To avert a serious threat to your health and safety or that of others.
For governmental purposes such as military service or for national security.
In the event of an emergency or for disaster relief.
In any other instance required by law.
Sign in sheet.
Company may also disclose your information to family members and/or other persons involved in your care or
payment for your care. Company may leave messages for you at work or home about your visits. If you do not want
us to do so, please inform our Privacy Officer in writing.
All other uses and disclosures of your information to others will require a written, signed authorization from you. You
have the right to revoke your authorization at any time except to the extent that we have already acted on it. Should
you require your records to be released, Company will provide you with an authorization form to complete and return
to the address listed on it.
YOUR HEALTH RECORD IS THE PHYSICAL PROPERTY OF PRACTICE. THE INFORMATION CONTAINED IN
IT BELONGS TO YOU. BELOW IS A LIST OF YOUR RIGHTS REGARDING INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION. ALL REQUESTS RELATED TO THESE ITEMS MUST BE MADE IN WRITING TO OUR
PRIVACY OFFICER AT THE ADDRESS LISTED BELOW. WE WILL PROVIDE YOU WITH APPROPRIATE
FORMS TO EXERCISE THESE RIGHTS. WE WILL NOTIFY YOU, IN WRITING, IF YOUR REQUESTS CANNOT
Restrictions on Use and Disclosure: You have the right to request restrictions on how we use and disclose
your health information. This includes requests to restrict disclosure of your health information to only
certain individuals or entities, involved in your care such as family members and insurance companies. We
are not required to agree with your request. If we agree, we are bound to the agreement unless disclosure
is otherwise required or authorized by law.
Confidential Communications: You have the right to request that we communicate with you in a particular
manner or at a certain location. For example, you may request that we only contact you at home. We will
accommodate reasonable requests.
Access: You have the right to inspect or request a copy of records used to make decisions about your health
care, including your medical chart and billing records. This office will schedule appointments for record
inspection. We may charge a fee for providing you copies of your records. Under special circumstances,
we may deny your request to inspect and/or copy your records. You may request a review of this denial.
Record Amendment: You have the right to request amendments to your health records created by and for
this Company if you feel they are incorrect or incomplete. We may accept or deny your request. If we deny
your request, you have the right to provide a statement of disagreement or rebuttal statement.
Accounting of Disclosures: You have the right to receive an accounting of the disclosures. This means you
may request a list of certain disclosures Company has made of your records. Upon your request, we will
provide this information to you one time free during each twelve (12) month period. There may be a fee for
Copy of Notice: You have the right to request that we provide you with a paper copy of this notice of Privacy
If you have any questions about this notice, please contact Practice’s Privacy Office; (480) 610-6100
Acknowledgement of Receipt of
Notice of Privacy Practices
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices that outlines how patient
confidential information will be used, disclosed and protected.
Name/Relationship if signed by individual other that patient: