New Patients In-Take

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete test is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal exchange of information necessary to provide you with medical services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We Have Adopted The Following Policies:

• Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
• It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
• The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
• You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
• You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
• Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
• We agree to provide patients with access to their records in accordance with state and federal laws.
• We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
• You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force form this time forward.

This Release of Information will remain in effect until terminated by me writing.

Financial Policy

Thank you for choosing the office of Dr. Alok Krishnna/Family Medical Clinic of Greater Sacramento. Our primary mission is to deliver the best and most comprehensive family care available. An important part of the mission is to deliver the best and most comprehensive family care available. To make the cost of uncovered care as easy and manageable as possible, we offer several payment options.

Payment options include: Cash, Visa, MasterCard, and checks up to $50.
If you are using a credit card, there is a processing fee of $3-$10.

Please Note: We require payment prior to the completion of your treatment. If you choose to discontinue care before your treatment is complete, your refund will be determined upon review of your case. However, a missed appointment will result in a $50 fee.

We want our patients to know how much we value their business. In the effort of providing the highest quality of care we require at least two days prior notice for any schedule changes you may need in the future. We would like patients to know how crucial a missed appointment is, not only for your care but also for other patients seeking treatment. A missed appointment may delay or prevent them from getting proper care. As a result, a missed appointment will result in a $50 fee.

If you need any additional paperwork that requires a signature from a physician/provider, extra charges will be incurred. These documents can be FMLA, Parking Sticker Permit, or EDD, etc. These charges are usually $50 but it can be more or less depending on paper work.

Our office can process immigration physicals, I-693 form (https://www.uscis.gov/system/files_force/files/form/i-693.pdf?download=1). The immigration department requires a detailed history, physical, immunization, labs, and possibly an X-ray. At certain times, this can be covered by your insurance. We have negotiated rates for labs, X-rays, and vaccines that are cheaper than paying directly to the vendor in case you have to pay cash. If you wish to pay through the clinic. Please check https://www.uscis.gov/forms for the requirements. You must read these requirements prior to coming to the clinic.

If you need a referral to see a specialist, it is very important that we document in your record why you need these services, as insurance requires that information we have documented your need, the information is sent to the insurance provider and they approve your visit to the specialist or any test that you need. Once we have approval from your insurance provider, we let you know, so you can make your appointment with your specialist. This also applies to medication, labs, or any other medical services. There is always a delay in this process, as we here at the clinic do not control the situation. It can take up to 30 days.

If a patient’s provider orders a lab/imaging it is your responsibility to check with your insurance where you can have your lab/imaging done. Sometimes they need prior approval. Any cost incurred is the patient's responsibility, not the clinic’s.

Our policy is to provide the best care. We advise our patients to make an appointment to discuss their results in-person. You can request for a virtual appointment (telemedicine) if it is allowed by the insurance. If you do not wish to come to discuss your results in-person at the clinic, you can sign up for our patient portal and have access to the same information.

The specific protocol is outlined below. Patients are requested to acknowledge that they read the protocol and agree to abide by its provision. All clinic personnel have also reviewed the protocol and will implement and abide by it. Unless the physician personally consents to a request for a deviation from the protocol, it will be followed explicitly.

• All medication requests, if approved, will be filled within 72 hours (usually sooner) after the request has been received either from the pharmacy or the patient. It is important that patients monitor the amount of medication remaining in their current prescriptions in order to avoid running out of medicine before a refill can be called in.
• Without written authorization from the doctor, a patient who has not yet been examined within the preceding 90 days and is requesting refills of medication may not have the medication refilled.
• If a request for a medication refill has been denied, the patient will be notified as soon as possible and will be given the reason why the medication will not be refilled. The patient may be directed to schedule an appointment for examination in order to ensure that the medication requested is, in fact, still appropriate for their condition.
• In connection with certain medications, the patient may be requested to have a blood test every three to six months to allow continued usage of the medications.
• Medication refill requests will be taken and processed during normal office hours only.
• NO narcotic pain medication will be prescribed.
• Narcotic pain medication is used for acute pain, such as that associated with recent injury or surgery, and are not used for the management of long-term or chronic pain. A referral to one of several pain management groups is available for patients in need of long-term management.
After reviewing the protocol, I understand and agree to its provisions.

Thank you for your cooperation, we remain committed to your health.

Indications for Use

Antipsychotic medications are approved to treat symptoms including Depression, Anxiety, Disorganized thinking, Impaired Concentrations, Delusions, Hallucinations and Sleep disturbances.

Goals of treatment with this drug should focus on improvement of quality of life, and reduced risk of negative behavior symptoms impacting you, or those around you. Ongoing assessment of the benefits of therapy, compared to the potential risks, should be performed regularly to maximize the potential for positive outcomes.

It may take a few weeks before improvement is felt after beginning the medication. It is important to take your medication as the physician prescribes it.

Side Effects

Any medication may produce unwanted effects along with the desired results. Some side effects may appear even before any benefit from the medicine is experienced. If side effects do appear they may occasionally disappear with continued treatment. Examples of side effects with drugs in this class may include, but are not limited to: Fall in blood pressure with body position changes, Dizziness, Constipation, Weight Gain – Increased Appetite Sleepiness or sedation, Dyspepsia, Dry mouth, Tremor or twitching, including feelings of restlessness, Agitation, Back or joint pain, Irregular heartbeat Stuttering Amnesia, Sensitivity to the sun

ALL SIDE EFFECTS SHOULD BE REPORTED & DISCUSSED WITH THE DOCTOR

Warnings and Precautions

Blood Sugar Effect- Increases in blood sugar may occur and could be complicated by pre-existing diabetes.

Cerebrovascular Adverse Events- Events such as stroke, transient ischemic attack and even including fatalities, were reported in patients in trials of atypical antipsychotics in elderly patients with dementia- related psychosis.

Tardive Dyskinesia- This is a syndrome of potentially irreversible, involuntary, dyskinetic movements. It may develop in patients treated with antipsychotic drugs.

Drowsiness and Impaired Coordination- Because of possible drowsiness and some loss of muscle control, your ability to drive, operate machinery or perform other tasks requiring alertness and coordination may be impaired. For this reason, you should avoid such hazardous duties until you are familiar with the effects this medication has upon you. Do not take this medication with alcohol. Be aware that the effects of alcohol may be intensified.

Drug Allergy- Some people may be allergic to this medication. Symptoms may be skin rash, itching, sneezing, fever or swelling of the face and tongue. If you should experience any of these symptoms, call your physician immediately.

Pregnancy and Lactation- Women should notify their physician if they become pregnant or intend to become pregnant. Women should not breast feed infants while on this medication.

Body Temperature- Because of the potential impact of atypical antipsychotics on body temperature regulation, extreme caution must be used when doing any activity that could increase body temperature, such as exercising strenuously, exposure to extreme heat, or reduced fluid intake or dehydration.

The above information has been discussed with the patient, and/or guardian/conservator, if appropriate, who reports them to be understood and agrees to take the medication.

I acknowledge that I am responsible for following my physician’s recommendations and to do what is necessary to control and treat my condition.

I understand that the sole responsibility of my health and well being is in my hands in view of the above and that I cannot reasonably hold my physician responsible if I do not adhere to his recommendations and /or not take medications as I am instructed to do so.

Introduction

Family Medical Clinic of Greater Sacramento utilizes the use of electronic communications to enable health care providers at different locations to share individual client medical information for the purpose of improving client care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and /or education,and may include any of the following:

• Patient medical records
• Medical images
• Live two- way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits

• Improved access to medical care by providing care to patient even if the physician is at distant / other sites
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

Possible Risks

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician.
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal information.
• In rare cases, a lack of access to complete client records may result in adverse drug interactions or allergic reactions or other judgement errors.

By Signing This Form, I Understand The Following:

• I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine which identities me will be disclosed to researchers or other entities without my consent.
• I understand that telemedicine may involve electronic communication of my personal information.
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with Family Medical Clinic of Greater Sacramento staff, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my care.