Welcome to Thurston Medical Clinic
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- Valerie Cooper
- 6 years ago
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1 Welcome to Thurston Medical Clinic We want to thank you for choosing Thurston Medical Clinic as your partner in healthcare. We realize that there are many choices available and are pleased that you have chosen to place your trust in us. We value each and every patient and hope that your first experience with our office was a positive one. Please let us know if there is anything that we could have done better, either now or in the future. We look forward to building a relationship of trust and support which can grow over time. Through good communication and education our hope is to become your healthcare partner and give you the tools to make informed decisions about your healthcare. Our two locations have adjacent parking lots which can at times become full. There is street parking available within close proximity of both offices, and we will reimburse any meter costs. Just notify the front staff when checking in. Enclosed you will find paperwork we need you to complete and bring with you for your appointment. If this is not completed when you come in it may delay your appointment time. Please arrive 30 minutes prior to your appointment time for paperwork and insurance processing at check in as part of the patient registration process.
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6 Thurston Medical Clinic 147 S 52 nd Pl Springfield, OR Phone: Fax: AUTHORIZATION TO DISCUSS HEALTH INFORMATION (verbal communication only) Patient Name: Patient DOB: Identification password: (the authorized person below will need to know this password) Optional I authorize Thurston Medical Clinic to discuss the areas I have identified below with the individual listed (Friends and Family members). I acknowledge with the signing of this form the medical data to be released may include information that is specific to HIV/AIDs, drug and or alcohol and / or psychiatric treatment if I have initialed those items separately. If you choose to restrict disclosure to someone you previously authorized, please ask for our Restriction form. PLEASE PRINT (use black ink) Name and phone # of person authorized (One person per line) Relationship to you Unlimited access (to all information listed below) Financial information Discuss Treatment Appointment scheduling/cancellation Sexually transmitted diseases MUST BE INITIALED TO BE INCLUDED: Alcohol/Drug Treatment Psychiatric Information HIV/AIDS information Genetic information You have the right to revoke this Authorization at any time, provided you do so in writing. If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosure already made with your permission. To revoke this Authorization, please send a written statement to attention of Privacy Officer, 147 S 52 nd Place Springfield, OR The notice should include the full name and relationship of the person you are revoking privileges from, along with your full name, date of birth, current date and signature. The information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and is no longer protected under federal law. Signature Date This authorization will remain in effect unless a stop date is identified or a written notice to revoke is received. If the patient is a minor, the authorization will expire once the patient reaches the age of consent, which is age 15 per OR Stop Date: NOTE-THIS IS NOT A RECORDS RELEASE FORM
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11 Records Release Thurston Medical Clinic 147 S 52 nd Place Springfield, OR Phone: (541) Fax: (541) Authorization of Disclosure of Protected Health Information - Incoming FOR FORM TO BE VALID, ALL SECTIONS MUST BE COMPLETED I authorize (physician, office, or person): Address: Phone: Fax# To release my medical information to Thurston Medical Clinic. The specific medical records to be released is (please initial): All Medical Records for the past 2 years including chart notes, labs and imaging reports. I understand that medical records may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, or mental health concerns, discussion of HIV testing. I consent to have the above information released. OR Specific Medical Records from to or most recent. Please check medical records requested: Chart Notes Lab/Pathology Reports Imaging/Diagnostic Reports Immunization Records Specially Protected Information (please initial): I consent to disclosure of genetic testing information. I consent to disclosure of alcohol and drug treatment. I consent to disclosure of mental health treatment. I consent to disclosure of my HIV/AIDS information. The purpose of release for HIV/AIDS test result/record is for:. HIV test results may be released from to. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or have copies of any information to be used or disclosed under this authorization. I also understand that, if the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations. I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so. This authorization will remain in effect for one year from the date of signature unless a stop date is identified. To revoke authorization prior to an expiration date or stop date, a written notice to revoke is required. If the patient is a minor, the authorization will expire once the patient reaches the age of consent, which is age 15 per OR [Insert applicable date or event of expiration]. Patient Name Date of Birth: Signature of Individual or Authorized Representative Print Name of Legal Representative (if applicable) Date Relationship of Legal Representative to Individual
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