PATIENT ACCOUNTREGISTRATION
Nome
o Mole
Doteof Birth
Address
MoritolStotus: oSingle oMonied
n Divorced
o Femole
o Widowed
CitY lStote / ZiP
Phone
Business
Driver'sLicenseNumber
Home Phone
CellulorPhone
SociolSecuriVNumber
Employer'sNome
Employer'sAddress
Refened by
RESPONSIBI.EPARTY
o Check here if some os potient informotionond skipto insuronceinformotion
o Mole o Femole
Nome
Address
Home Phone
CellulorPhone
BusinessPhone
PRIMARYINSURANCEIN FORJT,IATION
o HMO
Nome of InsuroncePlon
Group #
lnsuroncelD #
CIIYlStote / ZiP
Address
Employer
Name of Insured
SSNof Insured
Dote of Birthof Insured
Relotionshipto Potient: o Self o Spouse o Child a Porent o Other (specify)
o POS o PPO a Other
SECONDARY IN SURANCEIN FORJT,IATION
o HMO
Nome of InsuroncePlon
lnsuroncelD #
Address
Nome of Insured
DOB of Insured
o POS o PPO o Other
Group #
CiN tStote I Zip
Employer
SSNof Insured
to Potient: o Self o Spouse o Child o Poreni o Other (specify)
Relotionship
CONTACTIN FORI'IATION
EMERGENCY
Relotionship
person
whot is wrong with you? a Yes o No
Con we tell this
Nome
Phone Number
- Pleaseread carefully and sign.
DISCLOSURE
I hereby ossignmy insuroncebenefits to be mode direclly lo the doctor ond/or his/herossociotes,for servicesrendered. I hereby otlest
thol the obove insuronceinformotion is occurote ond thol I om on eligible member of lhe stoted plon. I understond thot I om responsible
for knowing my benefils/coveroge. I will be finonciollyresponsiblefor oll chorges thot ore NOTcovered by my insuronce compony. I olso
ogree to poying oll co-poymenls, co-insuroncesond/or eleclive servicefees ot the lime of service. lf there ore problems collecting
poyment, ottorney's fees, colleclion ogency cosis ond ony reloied fees will be odded io my bill.
I oulhorizethe releoseof oll informolion other physicionsond insuroncecorriersupon request for the purpose of poyment for medicol
servicesond furiher ireolment of core by onolher physicion. I furlher ogree thot o photocopy of lhis ogreement shollbe os volid os the
originol.
I hereby ocknowledge thoi I hove reod, understond ond ogree lo hereby give consent lo ossess,ireot ond tesf.
Signoture
o Potient o Porent o Child
A n n L . M a i .M . D
o Legol Guordion
o Duroble Power of Attorney
4950BarrancaParkway,Suite207 lrvine,California92604
- (949)262-0700Fax
Phone(949\262-9700
Doie
o Other (specify)
J. StephenWikle.M.D
I
I
PHYSrC
IAN.PATIENT
ARBITRATION
A GREEME
NT
Article 1:.Agteementlo Arbittofe:lt isunderstoodthot ony disputeos to medicol molproctice, thot isos to whether
ony medicolservicesrenderedunderthiscontroctwere unnecessory
or unouthorizedorwere improperly.negligently.
or incompetentlyrendered,willbe determinedby submission
to oibitrotionos providedby Ccilifo;nio'tow,"oid
ncjt
pY o lowsuitor resortto court processexcept os Coliforniolow providesforjudici'olreviewof'orbitrotionproceedings,
Both portiesto ihiscontroct, Qy enteringinto it, ore givingup theirconsiitutionolrightsto hove ony'suchdispule
decided in o courf of low before o jury, ond insteod-orebicepting the use of orditrotion.
Article 2: AllCloims Musfbe Arbitroted:lt isthe intentionof the portiesthot thisogreement bind oll porl'ieswhose
cloimsmoy oriseout of or reloie to treotmentor serviceprovidedby the physicionincludingony spoLtse
or heirs
potient_ondony children,whether born or unborn,ot the timb of the bccunence givlngri'seto cny cloim
9f
Jhe
In tho nnca
nf nnrr n
preQnontmother the term "potient" hereinshollnneonboth the moiheiond ihe mother's
expected child or children.
All cloimsfor monetorydomoges exceedingthe jurisdictionol
limitof ihe smollcloimscourt ogoinstthe physlcion,
ond,the physicion'spodners,ossociotes,
ossociotion.
corporotionor portnership,
ond the em[loyees,ogentsond
estotesof ony of them, must be orbitrotedinc_luding,
without limitotion,cloimsfor lossof con3ortiumiwrongful
deoth, emotionoldistress
or punitve dcmoges Filingof ony crctionin ony courl by the physicicnto collectonyiee
from the potient shollnot woive the rightto compel orbitroiionof ony molprociice cloim.
Arficle 3: Proceduresond Applicoble [ow: A demond for orbitrotionmust be communicoied in writino to oll
porltes. Eoch port-ysholl select on orbitrotor (por1yorbiirotor) within ihirly doys crrd o ihird orbifroior (-neutrol
orbitrotor) sholl be selected by the orbitrotorsoppointed by the poities within ihir'1'y
doys of o demond for o
neutrolorbiirotorby either porly, Eoch porfy io ihe orbitrotionshcllpoy such por'ry'spro roto shoreof the expenses
ond fees of the neutrol orbitrotor,iogether with other expensesof the orbitrotionincurred or opproved by the
neutrolorbitrotornot includingcounselfeesor witnessfees,or other expensesincurredby o porty for such porty's
own benefii The portiesogree thot the orbitroiorshove the immunityof o jucliciolofficerfrom civilliobilitywhen
nntinn
i,,,
n l,,,v
ha
nnnnni'
vvvu',ty of orbitrotorunder thiscontroct Thisimmunityshollsupplement,not supplont,ony other
opplicoble stotutoryor common low.
Eitherporty shollhove the obscluterightto orbitroteseporotelythe issuesof licbilityond domoges upon written
requestio the neutrol orbitrotor
Theportiesccnsentto the interventionond joinderin ihisorbitrotionof ony personor entitywhich would otherwise
be o properodditionolporty in o court oction, ond upon such interventionond joinderony existingcourt oction
ogoinsisuch odditionolpersonor entityshollbe stoyed pending crrbitrotion
rha nnrtioc^^r6a rhct provisionsof Coliforniolow opplicoble to heolth core providersshollopply to dispr-rtes
withinihisorbttrotionogreement,including,but not limitedto. Code of CiviiProcedureSections340.5ond 667.7
ond CivilCode Sections3333I ond 3333.2Any pofi moy bring before the orbitrotorso motion for summory
judgmentor summoryodjudicotionin occordonce withthe Code of CivilProcedure,Discovery
shollbe conducted
pursuontto Code of CivilProceduresection l2B305, however,depositionsmoy be token without prioropprovol
of the neutrol orbitrotor,
Article4: GenerolProvisions:All
cloimsbosed upon the some incident,tronsoctionor relotedcircumstoncessholl
be orbitrotedin one proceedrng A cloim shollbe woived ond foreverborred if (l) on the dote notice ihereof is
received,the cloim,if ossededin o civiloction,would be borred by the opplicobleColiforniostotuteof limitotions.
or (2)the cloimontfoilsto pursuethe orbitrotioncloim in occordonce with ihe proceduresprescribedhereinwith
reosonoblediligence.With respectto ony motter not hereinexpressly
providedfor the orbitrotorsshollbe governed
by the ColifornioCode of CivilProcedureprovisions
relotingto orbitrotion
Adicle 5: Revocolion:This
ogreementmoy be revokedby writtennotice deliveredto the physicronwithin30 doys
of signoturelt isthe intentof thisogreementto opply to oll medicol servicesrenderedony iime for ony condition
Adricle6: RekooctiveEffecl: lf ootient intends this ocreement to cover servicesrendered before the doie it is
signed(including,but noi limitedto, emergencytrediment) potient shouldinitiolbelow:
Effectiveos of the dote of firstmedicol services
Potie
lf ony provisionof thisorbitrotionogreementisheld involidor unenforceoble,the remoiningprovisions
shollremoin
in fullforce ond shollnot be offected by the involidityof ony other provision,
I undersiondthot I hove ihe right to receive o copy of this orbitrotionogreement, By my signoturebelow, I
ocknowledgethoi I hove receivedo copy.
By:
By:
Physicion's
or Authorized
Representotive's
Signoture
Printor StomoNome of Phvsicion,
MedicolGrouoor Associotion
Nome
Potient'sor PotientRepresentotive's
Signoture (Dote)
(Dote)
By:
PriniPctient'sNome
(lfRepresentotive,
PrintNomeond Relotionship
to Potient)
A signedcopyof thisdocumentisto be givento the Potient.
Originol
isto be filedin Potient's
medicolrecords
FINANCIAL
LIABILITY
AGREEMENT
I understand
thatall co-payments,
co-insurances
and deductibles
are due at
'bill
the timeof service.We do not accepta
me laterpolicy'.
ThereareNO EXCEPTIONS.
I understand
thatif my insurance
doesnot issuepaymentwithin90 daysof
responsible
the dateof serviceI will be financially
for the entirebalance.I may pursue
carrierat thattimeto renderpaymentandoncesettled,if due,I will
my insurance
receivea refundfor any overpayment.
I understand
thatit is my responsibility
to informthisofficeof any changesin
if I failto keepthe
my insurance
coverage.ThisofficeWILLNOTre-billmy insurance
We ask you at EVERY
officeupdatedwithmy mostcurrentinsuranceinformation.
VISITif thereis anychange,pleasekeepus updated.
I understand
thatthis officeDOESNOTverifybenefitsat the timeof service.
forknowing
my benefits
forcontacting
my
I am responsible
andwillbe responsible
fordetails.We DONOTdothisforvou.
carrier
insurance
for all servicesrendered
I understand
responsible
thatI willbe financially
that
visits
health'
my
insurance.
This
includes
for'behavioral
covered
by
office
are NOT
anxiety,..)that
stress,depression,
are oftenNOTa coveredbenefit
issues('worries',
to ensurecoverage.
by HMOplansandmanyPPOs.You mayseea psychiatrist
LIABILITY
I understand
anytermsof thisFINANCIAL
thatif I violate
fromthis
familymemberswillbe discharged
I and all immediate
AGREEMENT
practice.I willbe heldfinancially
for any balanceremaining
responsible
on all
collectionand attorneyfees.
accounts(mineand my family's)plusany associated
Signature:
PrintName:
Ann L. Mai,M.D.
Date:
92604
Sutte207 lrvine,California
Parkway,
4950Barranca
- (949)262-0700
Fax
Phone(949)262-9700
J. StephenWikle M D.
TESTRESULTS
NOTIFICATION
DearPatient,
Wewillnotifyyouof yourtestresults,
including
X-rays,
bloodwork,Papsmears,
etc..,
Thisprocess
takesapproximately
TWOweeks.lf indicated,
we willcontactyou sooner
regarding
bytelephone
theresults
and/orfollow-up
instructions.
Mammogram
willbe maileddirectly
results
bytheradiology
office.WeWILLNOT
emailor mailouttheseresults.
HIVresults
canonlybe obtained
by makinga followupvisitwiththedoctor.We
cannotemailor mailtheseresults.Thiscomplies
withCalifornia
StateLaw.Thereare
no exceptions.
pleaseregister
To obtainresults,
at www.relavhealth.com
andsetupa newaccount.
Wewillemailyourresults
through
website.
this
WE DONOTEMAILTO YOUR
PRIVATE
EMAIL
ACCOUNTI
Wewillalsomailoutresults
to youif youdo notregister
online.However,
thismay
(and
you
yourresults
willreceive
takeMORETIME
later).
PleasewaitTWO(2)weeksfromthedateof thetest(s)performed
beforeyoucontact
ourofficefortheresults.Ourstaffis notpermitted
to releaseanyresultsbv telephone
yourresults,
pleasemakean appointment
lf youwouldliketo discuss
withthisofficeor
with
webVisit
(there
consult
thedoctor a
at www.relayhealth.com is a feeforthis),
I authorize
my physician
and/orthestaffto leavemessages
on my
voicemail,or witha familymember.
machine,
answering
Familymember
to exclude:
I requestthat NO messagesbe leftat any of my numbers.I takefull
responsibility
to makea followup visitwiththisofficeto obtainany of my results.
Signature:
P r i n tN a m e :
A n n L . M a i ,M . D
Date:
4950 BarrancaParl<way,
Suite207 lrvine,California92604
Phone(949)262-9700- (949)262-0700Fax
J. SteoheW
n i k l e ,M . D .
ANNUALHEALTHUPDATE
Dateof Birth:
Visit:
for
Reason
Dateof Visit:
Currentprescriptionmedications,vitaminsor supplements:
Nam e l
Allergies:
PASTMEDICALHISTORY
Pleasecheckif YOUhaveor had the following:
I Asthma
I Measles
I Heartattacks
I Emphysema n Rheumatic
I Mumps
fever/ heartdisease
I Strokes
n Chickenpox
I Sexually
transmitted
disease(s)
n Diabetes
r Birthdefects
I Tuberculosis
I Cancer type:
n lnjuries l Bro
tr Headconcussions
or injuries
n Hospitalization(s)
n Anesthesia n Local n Regional I General n Other/ Unknown
n Operations
r Cbracciden
n Otherseriousconditions
FAMILYHISTORY
Pleasecheck if any blood relative has ever had:
I Breastcancer(who:
I Othercancers(
r
I
n
n
r
Bleedingtendencies
Diabetes
Heartdisease/ heart attacks
Highbloodpressure
High cholesterol
) n Coloncancer(who:_)
/ depression
/ other)
) I Mentalillness(anxiety
n Osteoarthritis
/ Gout
I
n
I
n
Seizures
Strokes
Tuberculosis
Other
IF DECEASED
Causeof Death
Siblinq(s) M/F
Children M/F
SOCIALHISTORY
MaritalStatus: r Single n Married n Separated n Divorced r Widowed a Other
Are you sexuallyactive? n Yes r No lf yes, n with males n with females n with both
ls your sex life satisfactory?n Yes n No
Are you livingwith your spouse/partner?
n Yes r No
/ Other
Are there dependentsat home?
n Yes n No
Children/ Grandchildren
How often?
Do you drinkalcohol?
n Yes n No How much? _
How often?
Do you smoke now?
r Yes r No How much? _
Did you ever smoke?
n Yes n No Amount/ Quit date?
Do you use drugs?
r Yes n No How much I often?
Do you have pets?
n Yes n No Pleaselist:
Do you exerciseregularly?
r Yes n No Do you havean advancedirective? r Y e s r N o
Areyou employed?n Full-time n Part-time r Unemployed Occupation:
past5 yrs:
pastyr:
Timelostdueto healthreasons:In past6 mos?
(ovERPLEASE)
REVIEWOF SYSTEMS
PleaseCIRCLEif you .r,?i,'eany of the followingNOWand answerguesfionswith blanks:
GENERAL:Fever {:irills Weightloss Weightgain Fatigue Appetitechange Insomnia
SKIN: Acne Jaundict l"lives Eczema Psoriasis Rashes Boils Abnormalpigmentation
HEAD/EYES/EARS/ru{.I$E/THROAT:
HeadachesEyediseaseor injury Glasses Contacts
Doublevision lilul'ryvision Glaucoma ltchyeyes Runnynose Sneezing
Nosebleeds {.lrrc'nicsinustrouble Eardisease Poorhearing Dizziness
glands Thyroidtrouble
NECK: Stiffness Errl:""rrg;ed
RESPIRATORY:Frettrtent
colds Spittingup blood Cough AsthmaA//heezingEmphysema
Difficultybreathirrg Shortnessof breath Painwithbreathing Pleurisy Pneumonia
CVS: Chestpain Sltr.,rtrtess
of breathat rest/ withactivity Awakeningin nightsmothering
turoblocks Swellingof hands/ feet/ ankles Highbloodpressure
Difficulty
walkinr-r
Heartmurmur Valvularheartdisease Palpitations
DIGESTIVE
SYSTEM;Iioodsticksin throat Heartburn/lndigestion
Ulcer Nausea Vomiting
riallbladder
Vomitingblood
disease Livertrouble Hepatitis Cramping Gas/Bloating
Diarrhea Con:,:!"ir:;ltion
Painfulstools HemorrhoidsBloodystools Blackstools
GYNECOLOGICAL:Arr,',ueriodsstarted:
How long do periodslast?
Frequencyof pe:;'.-,ds:Every
Birthcontrol
days Painfulperiods PMS Menopause
(date/ reason:
Hysterectomy
Numberof pregr::,rnr;ies
Numberof abortions/miscarriages
Dateof last perir.,! ,
Last Pap
Normal/ Abnormal
Date of last man'rrlrrrgram
Normal/ Abnormal
Have you ever hr;,,.i
an STD? n No o Yes
List all hormonestaken (pasUpresent)
GENITOURINARY:
Kir.lr:tly
stones Lossof urine Frequenturination Burning/painful
urination
Bloodin urine V.*e;ifl?l
/ Urethraldischarge Circumcised?
Y / N Testicularpain/ swelling
'/aricose
MUSCULOSKELETAL:
veins Weaknessof musclesor joints Difficulty
walking
Pain or swellingol juints Back pain (where?
chronic?Y / N)
Scoliosis Pain irr truttock/calves
while walking,relievedwith rest
ENDOGRINE:Thyroid ui:;ease Changein haUglovesize Hair loss Always hot / cold
Currentwt
Cunent height
Dryskin
Coarsehair
HEMATOLOGIC:
Slowlr,rralingEasybruising Anemia Phlebitis BloodClots
NEUROPSYCHIATRIG;
!-ightheadednessFainting
spells Numbness Tingling Paralysis
Weakness Cr:trv,.;lr;isns/Seizures
Undera lot of stress Anxiety Depression Bipolar
SuicideAttempts [Jisinterest
in usualactivities HopelessnessWorthlessness
Poorconcentratior:Anorexia Bulimia
PREVENTIVE:
Lasttetar:ilsshot
Lastflu shot
Last pneumoniasii':rt
Lastscreenfor coloncan@r
Last prostate exram"",
LastPSA
ysur
Name& numbered'
dentist
Patient'ssignature:
Date:
Reviewedby:
Date:
ANNMAl,M.D.andJ. STEPHEN
WIKLE,
M.D.
4950Bananca
Parkway,
Suite207# lrvine,California92604
Tel(9a9)262.9700
Fax
# (949)262.0700
NOTICE
OFPRIVACY
PRACTICES
Effec'tive:
April14,2003
OURPLEDGE
privacy
of lheirmedical
of ourpatients'
andlheconfidentialiV
informatron
Theprolection
your
beenimporlant
lo us, Weunderctand
thatyoutruslus to safeguard
hasalways
personal
our
rnformation
and rcspeclyour rightto privacy.This noticarepresents
hcallhinfomalion
thepdvacyof yourprotected
andlo inform
to maintain
commitmont
you of our legal&ties andprivaclpractice,as wellas yourrights,as required
by
youa copyof lhisnolice
required
to provide
andfedaral
law. Wearelegalty
California
currently
in eftct,
andto followthetermsof thisnotic€
INFORMATION
YOURPERSONAL
youandwemayreceive
caroweprovid€
records
oflhemedical
srmilar
Wekogprgcords
so thstw€,oI olhsrhealthcarsprovid€rs,
can
fromothers.Weusethisinformation
for services
andenableus to meetour
cars,obtainpayment
renderqualitymedical
praclico.Wemaystotethrs
profeseional
lo oporato
ourmedtcal
andlogalresponsrbiltltes
makes
upyourmedicai
in a charlandin ouromputers,Thisinformation
information
however
thisnoticeexplains
howwa use
recordis ourproperty;
record,Ihe medical
lo sharethatinformation
withothers
aboulyouandwhenweareallowed
informalion
PRACflCES
OURPRIVACY
olectronic
reasonable
andfeasiblephysicel,
andprocoss
It is ourpolcyto mainlain
accoss
to andprol€clthoavailability
andinlegrity
of
to r$tric1unauthorized
safeguards
yourheallhinlormation.
m€asures
may includesecuredofficehcilities,lockedfile cabinets,
Our protective
protected
accounls.
compuler
n€twork
systems
andpagsword
managed
ona 'need-to-knorv"
basis.Oncelheneed
information
is onlygrantcd
Access
to health
information
is limited
lo theminimum
nocessary
to acconplish
lhoacc€ss
is established
purpose.
lheintended
andprocedures
designed
tocomply
withthepolicies
lo proleclthe
Ourslaffarerequired
of yourheallhinbrmalion,Anystaffthstviolaleourprivacypolicyere
confidentiality
action
subject
todisciplinary
HOWWEilAY USEOR
YOURINFORilATIOII
SHARE
situationg
wh€rethe lawallovrsw to us€andshare
Thefollowing
categories
describo
yourhealthinformation.
foro€chcalegory
lhatillustrato
Wcgiveexamples
thaltlpe of
useor disclmurc,Nolcveryuseor discl€urois listed,butlhewaysin whrchwc are
lo useandsharoyourheallhinformalion
will hll inlooneof these
legallypermitted
calegories
Trcrtmcnt
We usemedical
informalion
aboutyou lo provideyourmodrcal
care, W€ disclose
andolherswhoerginvolved
in providing
modical
tnlormation
lo ouremdoye8s
th€care
youneed.Forexample,
w€mayshereyourmedical
informelion
withotherphysiciang
or
whowillprwideservices
whichwe do notprovide.Orwe
otherhealthcareproviders
maysharclhisinbrmation
witha pharmacisl
whonee&il lo disponse
a prescription
lo
you,ora laboralory
lhatporforme
a lert.
We may use and disclosemedicalinformation
lo contactand remindyou about
lf youarengthgme,we mayleavelhisinformation
on youranswering
appointmonls,
lefiwilhlhcperson
answering
machine
orine meosage
lhephone
HcslthCrro0pcratlons
Wo may useand disclosemedicalinformation
aboutyou to prop€rlyoperateand
pfaclice.Forexample,
manage
ourmedical
wemayusoanddisclose
thisinformation
to
reviewand improvelhe qualityof the carewe provide,or lhe comp€tonco
and
qualifications
of ourprofessional
staff. Orwemayuseanddisclcethisinformation
to
getyourhealthplanto authorrze
services
or referrals,Wemayalsougeanddisclose
lhisinformation
as necessary
for medical
revials,legalseruicee
andaudits,including
programs
planning
fraud,wasteandabusedetection,
compliance
andbusiness
and
Wemayalsoshareyourhealth
manag€ment,
information
withourbusiness
agsciates,
suchasourbillingservice,
thatp€rform
seruices
forus. However
wewillnotshareyour
healthinformation
wilhthemunlesstheyagreein writingto protoct
theprivacyof that
information
UnderCailfornia
lawall recipients
careinformalion
of health
areprohibited
fromre-disclosing
it sxceptas specifically
required
or permitted
by law. Wemayalso
plansthathavea
shareyourinformation
wilholherprovidoB,
clearing
houses
or health
relalionship
withyou,whentheyrequest
thisinformation
to helpthemwiththerrquality
and improvemant
assessment
activities,
lheir efiorh to improvehealthor reduce
qualifications
heallhcare
costs,lheirreviewof compolonce,
andprformance
of health
progmmg,
careprofessionals,
lheiriraining
theiraccredilation,
csrlification
or licensing
ortheirhealth
activilies,
carefraud,wasleandabusedetection
andcomplianco
efiorls
Notlflcatlonr
Wemaydisclose
information
tosomeone
whois rnvolved
withyourcareor holpspayfor
yourcar6, Wemaydisclose
yourhoallhinformalion
to notity,or assistin notifoing,
a
yourpersonal
percon
familymember,
reprggenlattv€
oranothor
responsible
foryourcare
aboulyourlocation,yourgeneralcondilionorintheeventofyourdeath,
Intheewnlof
a disaster,
we mayalsodisclose
information
lo a relieforganizalion
so thaltheymay
coordinale
thesenotification
efrorls.
Mrrk tlng
youto giveyouinformalion
Wamaycontact
aboutproducts
or sclicegrelated
to your
lreatment,
casemanag6m6nt
or carecoordination,
or lo dir€clor recommend
olher
ksalmsnts
or health-relaled
benefits
andservices
thalmaybeof interest
to you,or lo
provide
youwithsmallgifts We mayalsoencourage
youto purchaso
a productor
servrco
wnenwesaeyou
Rersrrch
circumstancss,
Under
cortaln
wemayuseanddisclose
medical
inlormation
aboutyoufor
purpo3osForexample,
projeclmayinvolve
rosoarch
a research
comparing
thehealth
of allpatienis
8ndrocovery
whorocsivod
onomodicalion
lo thosowhorsceivod
another,
projects,
forthesamecondition.
Allresearch
howevar,
aresubject
to a special
approval
proc€ss
Chcumrtrnccr
Spcclal
andthcLrw
Special
siluations
andcartainlawsmayrequire
yourhealth
us lo uss or release
infomalion.
Forexample,
yourheelth
we maybe roquired
to r€lgaso
informetion
to
othersforthefollowing
reasonst
r
.
yousigninwh6nyou
information
aboutyoubyhaving
Wemayuseanddiscleemcdicel
anivaat ouroffics,Wemayalsocalloulyournamcwhenwcarereadyto seeyou.
r
Pryncnt
medical
aboulyouto obiainpayment
Weusaanddiscloso
information
forthesorvices
weprovide.Foruample,wegiveyourheallhplantheinformation
il r€quiros
boforoil
prd/idor8
willpayus. Wemayaleodiscloso
informetion
to otherhoalthcare
to a8si8t
payment
you.
foraervicea
ihryprovido
theminoblaining
o
Whenever
wearerequired
to dosoby law;forexample,
lo thooxtentyour
careiscovered
byWorkers'
Compensation,
wewillmakeperiodic
reporls
to
youremployer
aboutyourcondition.
Wearealsorequired
by lawto report
casesof occupation
relatedinjuryor illnessto theemployer
or Workers'
Compensatron
insurer
To reporlinformation
to agencres
thatregulate
ourbusiness,
suchas the
U.S. Deparlmenl
of Healthand HumanS6rvicos
and the California
Department
of Health
andManaged
Care.
To assrsl*ith publichcalthaclivitics;
for example,
wc mayreporthealth
information
to lhe Foodand DrugAdminisliation
for lhe purposoof
investigating
or kacking a prascription
drug and medicaldevice
malfuncliom.
To reportinformation
to publicheaithagoncies
if we believelhereis a
ssriousthroallo yourhoallhandsafetyor thatof anolherpenson
or the
genoral
publicllhisincludes
disaster
reliefefforts
to health
oversighl
forexample,
activities
agencies;
wemay
Toreporlcertain
inspections,
licensure
involving
andpeerreviews
aclivilies
audits,
report
agencies;
for example,
we mayprwide
To assistcourlsor adminiskalive
pursuant
oI su@na, or when
lo a courlorder,searchwarrant
information
of a fulyauthotized
administratve
agenry
bytheinvesligation
required
aclivities;
forexample,
we mayprovide
health
la^,enforcemenl
Tosupporl
agentsfor lhe puposeof identilingor
to hw enforcement
information
person
witness
or missing
material
a fugitrve,
localing
lawenforcement
officials
or military
inslitutions,
authorities
To conectional
thathaveyouintheirlarful ctstody
authorilyregarding
childabuse,
to a go/emmenl
To reportinformation
ordomestic
violence
neglect
examiner
as authorized
by
witha mroneror medical
To shareinformalron
lo
wilhfunemldireclors,
as necessary
law. Wemayalsoshareinformation
carryouttheirduties.
for procuremenl,
or hansplantation
of
banking
To useor shareinfomation
eyesorlbsues
organs,
injunes
as required
byyourslate
regarcing
Toreportinformation
lob-related
laws
compensaiion
wdrkers'
govemmeni
functions,
suchas
relaledto specialized
To shareinformation
national
securityand counter-intelligence
activities,
militaryandveterans
purposes,
for lhe President,
or in support
of prwidingproteclveservices
persons
heads
of slaleandotherdestgnated
foreign
(1)if
circumstances.
or friendunderanyof thefollowing
Toa hmilymember
(2) if youare
to allowsucha disclosure;
youprwidea vebalagreement
andyoudo notraisean
givenanopportunity
lo obiectlo sucha disclosure
basedon our
or (3)if il canbe infenedfromthecircumstance,
oblection,
judgment,
professional
thatyouwouldnotobiect
withanother
is soldor merged
organizalion,
In lhewenl thatarr praciice
of lhe newowner,allhough
lhe property
yourmedrcal
recordwillbecome
thatcopiesof yourhealthinformation
therQhtto request
youwillmaintain
group.
physician
0r medrcal
toanother
belransfened
whenit has been"deWe may use or shareyourhealthinformalion
is considered
de-identified
whenit hasbeen
Healthinformation
identified.'
personally
you
idenlifo
processed
insucha waythatit cannolonger
anyinformation
Wemayalsousea'limiteddataset'lhaldoesnolcontatn
identi!you. Thislimileddatasetmayonlybeusedforthe
thatcandirectly
publichealthmallersor heallhcareoperationsFor
purposes
of research,
yourcily,countyandzipcode,but
a limileddatasetmayinclude
example,
notyournameorskeeladdress.
PERI'ISSION
YOURWRTTTEN
permilted
Praclices,
or asotherwise
bylaw
inthisNotice
of Privacy
Excepl
asdescribed
- priorto usingor
- calledan aulhorizalion
we mustobtainyourwriltenpermission
you as an individual.lf you providean
that identifies
sharinghealthinformalion
yourauthorizalion
yourmind,youmayrevoke
inwriting
at
authorization
andthenchange
anylrme.
we will no longeruseor shareyourheallh
hasbeenrevoked,
Oncean authorizahon
youshould
form,however
beawarethalwe
in theauthorizatton
information
asoutlined
madeingoodhith based
thatwaspreviously
a useor disclosure
won'tbeablelo retract
fromyou.
onwhatwasthena vahdauthotization
law we may not shareyour health
above,underCalifornia
Exceptas specified
youprovide
usanaulhorizatton
lo
or benefilplanunless
rnformation
withyouremployer
ooso.
OTHER
RESTRICTIONS
lawsregarding
the useanddisclosure
of health
In California
lheremaybe addilional
genelE
lo HIVstatus,communicable
diseases,
reproducttve
health,
information
related
Generally
abuse,mentalhealthandmentalretardation.
wewill
testresulb,substance
moreprolection
lawis moresiringeniandprovides
be boundby whalever
for your
privary.
YOURRIGHTS
Youhavetherighl
toyourhealthinformation.
Thefollowrng
areyourrighlswilhrespect
lo.
for lreatment,
Ask us to restricthowwe useor shareyoul healthinformation
paymenlor healthcare opetalions. You also have lhe right to ask us to
that we have been asked to give to famity
restrhi health rn{ormatron
memberso. to otherswho are invofuedin your healthcare or paymenlfor
your healthcare Pleasenole lhat whilewe will try to honoryour requests,
we arenol requiredby law to agreelo thesetypesof restrictions;
Request
confidential
communrcations
of healthinformation.
Forexample,
you mayask lhat we sendinformaton
lo yourworkaddress.We will
accommodate
allreasonable
requests
submitted
inwriling;
Inspect
andcopyyourheallhinformalion,
withlimited
exceptions.
Toaccess
yourrecord,youmuslsubmrta wrillenrequesldelailing
whalinformation
youwantaccesslo andwhether
youwanllo inspeclit or gela copyof it.
youa reasonable
Wemaycharge
feeforcopiesasallowed
by law. Under
cerlaincircumstances
we maydenyyourrequest.lf we do denyyour
request,
wewillnoti! youin wntingandmayprovide
youtheopportunity
to
havethedenialrevierved;
Requestan amendmenl
to your heallhinformation
that you believeis
inconecl
yourrequesl
or incomplele.
Wemayrequire
bein writing
andthat
youprovidea reasonfor therequest.
lf we maketheamendment,
we wrll
notiiTyou lf we denyyourrequest,
we will noli! youof the reasonin
writing. Thiswrillennolification
will explainyourrightto file a written
statement
of disagreemenl.
In return,we havea rightto rebulyour
youhavelherightto request
statement.
Furthermore,
thalyourinitialwritten
request,
ourwritlendenialandyourstatement
of disagreemenl
be included
wilhyourhealth
foranyfuturedisclosures;
information
Recele an accounting
of certaindisclosures
of yourhealthinformation
madeby usduringthesixyearspriorlo yourrequest.Wemayrequire
that
yourrequesl
you
be in wriling.Yourfirslaccounting
is free.Subsequently,
areallowed
requesl
onefreeaccounling
wery 12monlhs.lfyourequest
an
addilional
accounling
wilhin12 months
yourfreeaccounling,
of receiving
we
youa fee. Please
maycharge
you
nolelhatwearenotrequired
lo provide
foranyinformation:
withanaccounling
D
D
priortoApnl14,2003,
Disclosed
paymenl
Shared
forlreatment,
or healthcareoperations
asdescribed
ADOVE,
)
!
)
!
)
)
)
)
Previously
disclosed
toyou;
Shared
requesl;
aspadofanauthorizalion
permitted;
Incidental
to a useordisclosure
lhatisotherwise
Provided
foruseina facility
directory;
Provided
to personsinvolved
in yourcareor for olhernotification
pufposes;
Shared
fornalional
purposes,
security
ormunter-intelligence
Shared
orusedasoartof a limileddatasetforresearch.
oublicheallh
puDoses;
or heallh
careoperations
Disclosed
lawenforcement
to correctional
institutions,
officials,
military
authonties,
oversight
or health
agencies.
CHANGES
practces
Should
anyof ourprivacy
change,
wereserye
therighlto change
lhetermsof
lhisnoliceandio makelhe newnoticeeffective
for all theheallhinformation
lhal we
mainlain,
regardless
of whenit wascrealed
youa copyof
or receivedWewillprovide
noliceandwillpostit publicly
therevised
bylaw
asrequired
OUESTIONS
ORCOMPLAINTS
praclices,
lf youhaveanyquestrons
regarding
thisnotice
of privacy
ifyot require
yourprivaryrightshavebeenviolated,
please
additional
information,
oryoubelieve
conlact
Offrcer
ourPrivacy
al.
4950Bananca
Parkway,
Suite207
lrvine,
CA 92604
(949)262-9700
youandyouwillnotbepenalized
Noaclionwillbelakenagainst
in anywayforflinga
complaint
wilhus.
lf you prefer,you maydirectyourcomplaints
lo the Secretary
of the UnitedStates
of Health
Deparlment
andHuman
Services.
A n n L . M a i , M . D .a n dJ . S t e p h e nW i k l e ,M . D .
lnternal Medicine
4950 BarrancaParkway,Suite207
l r v i n e ,C a l i f o r n i a9 ? 6 0 4
Phone(9+S1262-9700 - (g+g) 2GZ-0700 Fax
Acknowledgementof Receiptof Noticeof Privacy Practices
PrivacyOfficer:MichelleEibl (949)262-9700
EffectiveDate: April 14,2Q03
Name of Patient:
DOB:
that I receiveda copyof the Noticeof PrivacyPracticesfor the above
I herebyacknowledge
physicians.I furtheracknowledge
that a copyof the currentnoticeis postedin the reception
areaandthatany amendedNoticeof PrivacyPractices
will be madeavailableat my next
appointment.
Signature:
Date:
PrintName:
Telephone:
lf not signedby the patient,pleaseindicaterelationship:
! parentor guardianof a minorpatient
patient
ll guardianor conservator
of an incompetent
or personalrepresentative
of deceasedpatient
! beneficiary
nunnnnnnEIItrEu11nnnnuungnEg11uuuunIIgnnnunnnnn
Noticeof PrivacyPracticesAcknowledgementTrackingInformation
thefollowingonlyif the patientrefusesto signthe Acknowledgement:
Complete
Effortsto Obtain:
Reasonsfor Refusal:
E m p l o y eN
e a me :
RECORDS
RELEASE
TO:
Name of Doctor/ MedicalGroupor Clinic
AddressI CityI State/ Zip
Telephone/ Fax
n n E11n n u n n E n 11n n u Eu n En II u E n II n nn EUn II Un n EUn n Un E
I HEREBY
AUTHORIZE
ANDREQUEST
YOUTO RELEASE
TO:
I Ann L. Mai,M.D.
! J. StephenWikle,M.D.
4950BarrancaParkway,Suite207
hvine,California92604
Phone (949)262-9700-- (949)262-0700Fax
THECOMPLETE
MEDICAL
RECORDS
IN YOURPOSSESSION,
FORPERIOD
FROM
TO
. lf thereis a chargefor this
service| (thepatient)am responsible
for the fee. Do not billmy newdoctor'soffice.
Nameof Patient:
Patient's
SSN'
DOB:
Telephone:
Patient's
CurrentAddress:
AddressI CityI State/ Zip
Signature:
Date:
PrintName:
lf notsignedby the patient,pleaseindicaterelationship:
I parentor guardian
of a minorpatient
patient
! guardianor conservator
of an incompetent
tl beneficiary
or personalrepresentative
of deceasedpatient
WitnessSignature:
WitnessName: