CLINIC FOR NATURAL HEALING.
Doctor Galina Danily, ND
503-984-9010, [email protected]
Patient Consent for Purposes of Treatment, Payment and
Information protection.
Purpose: for your best care and private information protection.
I consent to the use or disclosure of my protected health information by Dr Galina Danily office for the purpose of diagnosis or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations.
I understand that diagnosis or treatment of me by Dr Galina Danily may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Dr. Galina Danily is not required to agree to the restrictions that I may request.
I have the right to revoke this consent, in writing, at any time.
My protected health information means health information, including demographic information collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical and/or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review Dr Galina Danily Notice of Privacy Practices prior to signing this document.
Dr Galina Danily reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I may obtain a revised notice of privacy practices by calling Dr Galina Danily office and requesting that a revised copy be sent or by requesting one at my next appointment.
______________________________________ ____________________________
Signature of Patient or Personal Representative Date
______________________________________ ____________________________
Name of Patient of Personal Representative Date
______________________________________ ____________________________
Description of Personal Representative’s Authority Date
Doctor Galina Danily, ND
503-984-9010, [email protected]
Patient Consent for Purposes of Treatment, Payment and
Information protection.
Purpose: for your best care and private information protection.
I consent to the use or disclosure of my protected health information by Dr Galina Danily office for the purpose of diagnosis or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations.
I understand that diagnosis or treatment of me by Dr Galina Danily may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Dr. Galina Danily is not required to agree to the restrictions that I may request.
I have the right to revoke this consent, in writing, at any time.
My protected health information means health information, including demographic information collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical and/or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have the right to review Dr Galina Danily Notice of Privacy Practices prior to signing this document.
Dr Galina Danily reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.
I may obtain a revised notice of privacy practices by calling Dr Galina Danily office and requesting that a revised copy be sent or by requesting one at my next appointment.
______________________________________ ____________________________
Signature of Patient or Personal Representative Date
______________________________________ ____________________________
Name of Patient of Personal Representative Date
______________________________________ ____________________________
Description of Personal Representative’s Authority Date
CLINIC FOR NATURAL HEALING.
Dr Galina Danily, ND
503-984-9010, [email protected]
HEALTH HISTORY.
Patient Name :_______________________ Birthdate : ___/_____/____
Today’s date: ____________ Primary care physician: ______________________________
Please list all medicines you are currently taking (including non-prescription drugs): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Goals for Treatment Please list (in order of importance) the present health concerns, symptoms, or problems you have: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past Medical History diseases and dates: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Family medical history: list disease and relative relationship: ______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Please list all allergies: _________________________________________________________________________________ _________________________________________________________________________________
Habits such as alcohol, coffee, smoking, etc. ________________________________________________
To the best of my knowledge, the above information is correct. I understand that giving inaccurate information may harm my (my child’s) health. It is my responsibility to inform the doctor of any changes in my or my child’s medical status. I authorize the health care staff to perform necessary health care services.
Patient’s signature: ____________________________________________________________________
Date_____________________________________________
Dr Galina Danily, ND
503-984-9010, [email protected]
HEALTH HISTORY.
Patient Name :_______________________ Birthdate : ___/_____/____
Today’s date: ____________ Primary care physician: ______________________________
Please list all medicines you are currently taking (including non-prescription drugs): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Goals for Treatment Please list (in order of importance) the present health concerns, symptoms, or problems you have: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past Medical History diseases and dates: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Family medical history: list disease and relative relationship: ______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Please list all allergies: _________________________________________________________________________________ _________________________________________________________________________________
Habits such as alcohol, coffee, smoking, etc. ________________________________________________
To the best of my knowledge, the above information is correct. I understand that giving inaccurate information may harm my (my child’s) health. It is my responsibility to inform the doctor of any changes in my or my child’s medical status. I authorize the health care staff to perform necessary health care services.
Patient’s signature: ____________________________________________________________________
Date_____________________________________________
