New Patient Packet
Please fill out the below New Patient Packet in its entirety and review the Notice of Privacy and Health Care Recommendations before your scheduled appointment. If you need to make an appointment, please call 214-206-1445.
Please read the below Notice of Privacy Practices and Health Care Recommendations before signing the New Patient Packet.
Notice of Privacy Practices
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information.
Please review this notice carefully.
Our commitment to your privacy:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected, or PHI).In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
How we may use and disclose your PHI
Your privacy rights in your PHI
Our obligations concerning the use and disclosure of your PHI
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
If you have any question about this Notice, please contact:
Gladys Bloom 214-206-1445
Health Care Recommendations
By signing the New Patient Packet you are acknowledging that you have received and understand its content:
For Women:
Mammograms should be performed every other year after age forty and then yearly after age fifty. Self breast exams should be done yearly after age forty.
Pap smears yearly after the start of your menstrual cycle.
Bone density test should be done yearly after menopause.
For Men:
Digital prostate exam and PSA blood test should be done yearly after age fifty. Please note that the PSA blood test should be done before the exam.
For both Men and Women:
A colonoscopy should be done for every adult over the age of fifty. If you have a first degree relative (i.e. mother, brother) diagnosed with colon cancer earlier you should have the procedure done 10 years before the onset of the disease in that relative.
You should receive a yearly flu shot if you are older than 65 years, a Health Care worker, and/or Diabetic.
You should get a pneumonia shot every five years if you are older than 65 years, and/or had a splenectomy.
If you are Diabetic you should have the following:
Hemoglobin A1C level every three months. This is a blood test that measures your average blood sugar for the past 3 months before the test.
Yearly eye retinal exam performed by an Ophthalmologist and NOT an optometrist.
Bi-yearly foot exams to check for nerve damage and poor circulation.
Diet and exercise plan.