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Download new patient information and forms:

By completing these forms prior to your visit, you can improve the accuracy of your information and save time in the office on the day of your visit.

R. Daniel Bohl, MD

Urologist

Patient Information Form

PATIENT INFORMATION: (Please print)

Name: _________________________________________________________________

(Last) (First) (Initial)

Address: ______________________________________________________________________________

(Street Address) (City) (State) (Zip)

SS#: ____________________ Home phone: ( )______________ Work phone: ( )_____________

Birth date: _______________ Cell phone: ( )_______________ Marital status: S M W D Sep

Employer: _________________________________________ Occupation: ________________________

Work Address: _________________________________________________________________________

(Street Address) (City) (State) (Zip)

Primary care/Family Physician: ____________________________________________________________

Preferred pharmacy:___________________________________

Referred by: (Name and phone number): _____________________________________________________

SPOUSE and/or RESPONSIBLE PARTY INFORMATION:

Name: ________________________________________________________________________________

(Last) (First) (Initial)

Address: ______________________________________________________________________________

(Street address) (City) (State) (Zip)

Home phone: ( )__________________ Relationship to you: _________________________________

SS#: ______________________ Birth date: _____________ Occupation: ________________________

Employer: ___________________________________________ Work phone: ( )________________

Work address: __________________________________________________________________________

(Street address) (City) (State) (Zip)

PRIMARY INSURANCE:

Policy holder: (please circle one) Self Spouse Parent

Insurance Company Name: _____________________________________________________________

Insurance ID#: ____________________________ Group #: _________________________________

SECONDARY INSURANCE:

Policy holder: (please circle one) Self Spouse Parent

Insurance Company Name: _____________________________________________________________

Insurance ID#: ____________________________ Group #: _________________________________

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to R. Daniel Bohl, Urologist (Tax ID#26-3862244).

I authorize payment of medical benefits to R. Daniel Bohl, Urologist (Tax ID#26-3862244).

SIGNATURE:________________________________ DATE: __________________

Patient History

History of Present Illness

Chief Complaint (what is the reason for your visit?): _____________________________

_______________________________________________________________________

Past Medical History

List any known illnesses:

________________________ Year: ___ _______________________ Year:______

Prior surgery:

________________________ Year: ___ _______________________ Year:______

Height: ______________ Weight: _______________

Social history:

Marital status (circle): single married divorced widowed

Children:________ Occupation:___________

Do you smoke? (packs/day) _____ Alcohol? (per day) _______ Illegal drugs?_______

Allergies? (Include reaction):

_______________________________________________________________________

Current medications (including dosage and over-the-counter medications):

______________________________ _____________________________________

Family history (List all serious illnesses among your close blood relatives: i.e. diabetes, hypertension, heart disease, cancer, etc.)

______________________________________________________________________

Review of Systems

Do you have any of the following symptoms? Circle yes or no and explain positive responses.

Constitutional

Fever Y N
Chills Y N
Headache Y N
Other

____________________________

Eyes

Blurred vision Y N
Double vision Y N
Pain Y N
Other

____________________________

Neurological

Tremors Y N
Dizzy spells Y N
Numbness Y N
Other

____________________________

Respiratory

Wheezing Y N
Frequent cough Y N
Short of breath Y N

__________________________

Skin

Persistent itch Y N
Persistent rash Y N
Boils Y N

Musculoskeletal

Joint pain Y N
Back pain Y N
Weakness Y N

__________________________

Cardiovascular

Chest pain Y N
Hypertension Y N
Varicose veins Y N
Bleeding problems Y N

__________________________

ENT

Sinus congestion Y N
Sore throat Y N
Ear problems Y N

__________________________

Gastrointestinal

Indigestion Y N
Abdominal pain Y N
Diarrhea Y N
Constipation Y N
Bloody stools Y N
Nausea Y N

Genitourinary

· Trouble voiding Y N

· Bloody urine Y N

· Sexual problems Y N

___________________________

List any other physicians that you are seeing including their telephone and fax numbers:

_____________________________________________________________________

R. Daniel Bohl, M

Urologist

General Consent for Evaluation and Treatment

I, ____________________________________, agree to allow R. Daniel Bohl and his staff to evaluate and treat my medical conditions. I am aware that this evaluation and treatment may involve procedures that could cause some discomfort and risk.

I understand that Dr. Bohl and his staff will attempt to explain procedures that may cause discomfort or risk, and that I may ask and expect to have answered any questions about any procedures.

I understand that I may decide not to proceed with any evaluation or treatment at any time, and that my failure to decline any evaluation or treatment provided in the office will imply my willing consent to proceed.

Specific consents will be required for certain procedures provided in the office and surgical procedures performed in the hospital.

________________________________________ _______________________

Patient signature Date

Financial Policy

We are committed to providing you with the best possible medical care. If you have special financial needs, we will try to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

1) This practice participates with a variety of insurance Plans. We have certain contractual obligations to these Plans. It is your responsibility to:

Bring your current insurance card at every visit. We consider an insurance card to be similar to a credit card because you are asking us to bill another party for the services that we have provided to you.
Be prepared to pay your co-payment at each visit. We are required by your insurance plan to collect co-pays on the date of service. This avoids unnecessary bills and it is your and our obligation.

2) If you have insurance in which we do not participate, we can provide an itemized statement of charges that you can use to file for reimbursement.

3) If you have secondary insurance coverage, you should provide that information to us on the date of service. You will be expected to pay any co-payment that is required by your primary insurance carrier. The information about your secondary insurance carrier will allow us to file a timely claim and to avoid unnecessary billing.

4) Co-payment obligations, deductible patient obligations, and contractual adjustments to our bill vary greatly among insurance plans. The amount that you will be expected to pay is an obligation both to our practice and to your insurance carrier. In the event of hardship or inability to pay, please discuss the situation with us so that we can make arrangements.

5) If you have questions about insurance, we will try to assist you. Specific coverage issues are best directed to your insurance carrier service department.

6) Patients without insurance and who plan to pay for our services out-of-pocket are encouraged to discuss cash discounts and payment plans with us. Nobody benefits form repeated unpaid bills and delinquency notices.

7) We engage an outside agency to manage our billing and collections. They will be able to assist you with questions about your bill.

Our practice believes that a good physician-patient relationship is based on understanding and good communication. Please sign that you have read and agree to the Financial Policy.

________________________________________ _______________________

Patient signature Date

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

If you have any questions about this notice please contact Dr. Bohl or Brigid Bohl.

Effective date of this notice is March 1, 2009.

Our pledge regarding medical information:

We understand that information about you and your health is personal. We are committed to protecting the privacy of medical information about you. We create a record of the care and services that you receive in the practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or used by the practice, whether made by the practice’s personnel or by another doctor. Other doctors may have different policies or notices regarding the use and disclosure of your medical information created or used in that doctor’s office or clinic. This notice will tell you about the ways in which we may use and disclose medical information about you. The medical information that we have about you is called protected health information. We also describe your rights and certain obligations that we have regarding the use and disclosure of your protected health information. We are required by law to:

Make sure that protected health information about you is kept private;

Give you this notice of our legal duties and privacy practices with respect to protected health information about you; and

Follow the terms of the notice that are currently in effect.

How we may use and disclose medical information about you:

The following categories describe different ways that we use and disclose protected health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways that we are permitted to use and disclose information will fall into one of the categories. In this notice, the word “use” means to review, consult, read, update, and study your protected health information so we can provide health care to you to assure that we are caring for you in the best way that we can and to perform other activities permitted or required by law. The word “disclose” in this notice means that we are providing your protected health care information to someone outside our practice so that he or she can provide care for you, understand your health condition in order to explain it to you, learn more about your particular health condition, and so that we can get paid for providing health care to you, and other activities permitted by law. Following is a discussion of these activities:

For treatment. We may use protected health information about you to provide for medical treatment or services in our office. We may disclose medical information about you to other doctors, nurses, technicians, or hospital personnel who are involved in taking care of you at the hospital or in other doctor’s offices. We may disclose protected health information about you to other people outside our office who may be involved in your medical care such as family members, laboratory technicians, or health professionals outside our office who are involved in your care.
For payment. We may use and/or disclose protected health information about you so the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. We may send you a statement for our services that contains our return address on the envelope. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
For health care operations. We may use and/or disclose protected health information about you for business purposes of our practice. These purposes are activities such as assuring quality care for our patients and evaluating the performance of our staff. We may also share your protected health information with others who assist us in record keeping and billing.
Appointments and reminders. We may use and/or disclose protected health information to contact you or as a reminder that you have an appointment, to keep track of who is waiting in the office to be seen, and to call your name in the reception area.
Emergencies. We may also use and/or disclose protected health information about you for emergency treatment This could occur in a situation when you have come into our office and are unable to provide consent because of the condition of your health and the need for immediate treatment. If this happens, we will attempt to obtain your permission for this use or disclosure as soon as possible following the emergency treatment.
Individuals involved in your care or in payment for your care. We may disclose protected health information about you to a friend or family member who is involved in your medical care or who is involved in the payment for your care.
For communication purposes. We may use and/or disclose protected health information about you to a third party if we have significant difficulty communicating with you. For example, if you have difficulty understanding English or if you are deaf, we may wish to have an interpreter assist us in communicating with you.
Business associates. We may disclose protected health information to employees in other businesses who assist us in your health care treatment. When we use business associates to assist us in providing service to you, we require that they agree to safeguard your protected health information before we allow them to be our business associates and before we disclose any protected health information to them.
Correctional institution. We may disclose protected health information about you to individuals in correctional facilities so that you can receive appropriate care if you go to jail.
As required by law. We may disclose protected health information about you when required to do so by federal, state, or local law. If a law requires that we disclose protected health information about you, we will do so only to the extent required by law. Federal law permits and requires us to disclose your protected health information to agencies that do healthcare oversight, public health activities, workers compensation, food and drug administration, and similar legally registered activities. For example, state law requires that we report instances of communicable diseases, such as venereal disease, to the Health Department. Another example is if a drug or any other product prescribed to you has been recalled by the Food and Drug Administration, we may be required to disclose your name and identifying information to them.
Lawsuits, disputes, and subpoenas. If you are involved n a lawsuit or dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law enforcement. We may disclose protected health information about you if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, missing person, or material witness; about the victim of a crime under certain limited circumstances; in emergency circumstances to report a crime.

Your rights regarding health information about you

Right to inspect and copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to us no later than one week before you would like to inspect your protected health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect or copy in certain very limited circumstances. If you are denied access to protected health information about you, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to amend. If you feel that protected health information that we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the practice. To request an amendment, your request must be submitted to us in writing. In addition, you must submit a reason that supports your request. We may deny your request if: the information in question was not created by us; the information in question is not part of the protected health information kept by or for the practice; the information in question is not information that you would be permitted to inspect or copy; or the information in question is accurate and complete. If we deny your request for the amendment, we must let you know in writing. You have the right to disagree with our denial of your requested amendment.
Right to an accounting of disclosures. You have the right to request that we provide you with and accounting of disclosures in compliance with 45 CFR 164.528. This is a list of certain disclosures that we have made of your protected health information that were not related to treatment, payment, health care operations, or any other of the routine uses or disclosures described in this Notice, were not required by law, and for which you did not sign an authorization. To request this list or accounting of disclosures, you must submit your request to us in writing. Your request must state a time period, which may not be longer than 6 years. The first list that you request in any 12 month period will be free. For additional lists we may charge you the costs associated with producing the list. We will notify you of the cost and you may choose to modify or withdraw your request at that time before costs are incurred.
Right to request restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have a right to request a limit on the protected health information that we disclose about you to someone who is involved in your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request to us in writing. In this request, you must tell us what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.
Right to request alternative communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we communicate with you at work or by mail. To request confidential alternative communications, you must make your request to us in writing. We will accommodate all reasonable requests.
Right to a paper copy of this notice. You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

Changes to this notice:

We reserve the right to change this notice. We reserve the right to make the changed notice effective for protected health information we already have about you as well as any information that we create or receive in the future.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with the practice and with the Secretary of the United States Department of Health and Human Services. To file a complaint with the Secretary of the United States Department of Health and Human Services, send a letter to: Secretary, United States Department of Health and Human Services,

200 Independence Avenue S.W., Washington, D.C.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other uses of medical information:

Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us authorization to use or disclose protected health information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures that we have already made with your authorization, and that we are required to retain our records of the care that we provided to you.

Patient Acknowledgement Form

Notice of Privacy Practices

____ I have received a copy of Privacy Practices from R. Daniel Bohl, Urologist.

Patient‘s Name:________________________________ DOB:_____/_____/_______

Patient’s Signature:_____________________________ Date:_____/_____/_______

____Patient declined the notice of Privacy Practices from R. Daniel Bohl, Urologist.

Staff signature:_____________________________

---------------------------------------------------------------------------------------------------------

Ways In Which We May Communicate With You:

1) May we leave messages at your home? Yes No

2) May we leave messages at work? Yes No

3) May we leave messages on your answering machine at home? Yes No

4) May we leave messages on your voicemail? Yes No

5) May we mail information to your home address? Yes No

------------------------------------------------------------------------------------------------------

I understand that it is my responsibility to notify R.Daniel Bohl, Urologist in writing if I want to make changes to the above requests.

Patient’s Signature:____________________________________

R. Daniel Bohl MD

Urologist

Consent to Allow Disclosure of Protected Health Information

Your personal health information is private, and we may not legally disclose this information to others without your permission. Exceptions to this law are defined by the Notice of Privacy Practices that we have provided to you.

You may wish to give us permission to share your protected health information with certain individuals such as your spouse or your children. This form serves to give us that permission.

I, ______________________________, hereby grant to R. Daniel Bohl MD and his agents my permission to disclose and discuss my protected health information with the following individuals. I understand that I can withdraw this permission by written notice.

Name Relationship

____________________________ _______________________________

_____________________________ _______________________

Patient signature Date

_____________________________

Witness

Download new patient information and forms

By completing these forms prior to your visit, you can improve the accuracy of your information and save time in the office on the day of your visit.

R. Daniel Bohl, MD

Urologist

Patient Information Form

PATIENT INFORMATION: (Please print)

Name: _________________________________________________________________

(Last) (First) (Initial)

Address: ______________________________________________________________________________

(Street Address) (City) (State) (Zip)

SS#: ____________________ Home phone: ( )______________ Work phone: ( )_____________

Birth date: _______________ Cell phone: ( )_______________ Marital status: S M W D Sep

Employer: _________________________________________ Occupation: ________________________

Work Address: _________________________________________________________________________

(Street Address) (City) (State) (Zip)

Primary care/Family Physician: ____________________________________________________________

Preferred pharmacy:___________________________________

Referred by: (Name and phone number): _____________________________________________________

SPOUSE and/or RESPONSIBLE PARTY INFORMATION:

Name: ________________________________________________________________________________

(Last) (First) (Initial)

Address: ______________________________________________________________________________

(Street address) (City) (State) (Zip)

Home phone: ( )__________________ Relationship to you: _________________________________

SS#: ______________________ Birth date: _____________ Occupation: ________________________

Employer: ___________________________________________ Work phone: ( )________________

Work address: __________________________________________________________________________

(Street address) (City) (State) (Zip)

PRIMARY INSURANCE:

Policy holder: (please circle one) Self Spouse Parent

Insurance Company Name: _____________________________________________________________

Insurance ID#: ____________________________ Group #: _________________________________

SECONDARY INSURANCE:

Policy holder: (please circle one) Self Spouse Parent

Insurance Company Name: _____________________________________________________________

Insurance ID#: ____________________________ Group #: _________________________________

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to R. Daniel Bohl, Urologist (Tax ID#26-3862244).

I authorize payment of medical benefits to R. Daniel Bohl, Urologist (Tax ID#26-3862244).

SIGNATURE:________________________________ DATE: __________________

Patient History

History of Present Illness

Chief Complaint (what is the reason for your visit?): _____________________________

_______________________________________________________________________

Past Medical History

List any known illnesses:

________________________ Year: ___ _______________________ Year:______

Prior surgery:

________________________ Year: ___ _______________________ Year:______

Height: ______________ Weight: _______________

Social history:

Marital status (circle): single married divorced widowed

Children:________ Occupation:___________

Do you smoke? (packs/day) _____ Alcohol? (per day) _______ Illegal drugs?_______

Allergies? (Include reaction):

_______________________________________________________________________

Current medications (including dosage and over-the-counter medications):

______________________________ _____________________________________

Family history (List all serious illnesses among your close blood relatives: i.e. diabetes, hypertension, heart disease, cancer, etc.)

______________________________________________________________________

Review of Systems

Do you have any of the following symptoms? Circle yes or no and explain positive responses.

Constitutional

Fever Y N
Chills Y N
Headache Y N
Other

____________________________

Eyes

Blurred vision Y N
Double vision Y N
Pain Y N
Other

____________________________

Neurological

Tremors Y N
Dizzy spells Y N
Numbness Y N
Other

____________________________

Respiratory

Wheezing Y N
Frequent cough Y N
Short of breath Y N

__________________________

Skin

Persistent itch Y N
Persistent rash Y N
Boils Y N

Musculoskeletal

Joint pain Y N
Back pain Y N
Weakness Y N

__________________________

Cardiovascular

Chest pain Y N
Hypertension Y N
Varicose veins Y N
Bleeding problems Y N

__________________________

ENT

Sinus congestion Y N
Sore throat Y N
Ear problems Y N

__________________________

Gastrointestinal

Indigestion Y N
Abdominal pain Y N
Diarrhea Y N
Constipation Y N
Bloody stools Y N
Nausea Y N

Genitourinary

· Trouble voiding Y N

· Bloody urine Y N

· Sexual problems Y N

___________________________

List any other physicians that you are seeing including their telephone and fax numbers:

_____________________________________________________________________

R. Daniel Bohl, M

Urologist

General Consent for Evaluation and Treatment

I understand that Dr. Bohl and his staff will attempt to explain procedures that may cause discomfort or risk, and that I may ask and expect to have answered any questions about any procedures.

Specific consents will be required for certain procedures provided in the office and surgical procedures performed in the hospital.

________________________________________ _______________________

Patient signature Date

Financial Policy

1) This practice participates with a variety of insurance Plans. We have certain contractual obligations to these Plans. It is your responsibility to:

Bring your current insurance card at every visit. We consider an insurance card to be similar to a credit card because you are asking us to bill another party for the services that we have provided to you.
Be prepared to pay your co-payment at each visit. We are required by your insurance plan to collect co-pays on the date of service. This avoids unnecessary bills and it is your and our obligation.

2) If you have insurance in which we do not participate, we can provide an itemized statement of charges that you can use to file for reimbursement.

5) If you have questions about insurance, we will try to assist you. Specific coverage issues are best directed to your insurance carrier service department.

7) We engage an outside agency to manage our billing and collections. They will be able to assist you with questions about your bill.

Our practice believes that a good physician-patient relationship is based on understanding and good communication. Please sign that you have read and agree to the Financial Policy.

________________________________________ _______________________

Patient signature Date

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully.

If you have any questions about this notice please contact Dr. Bohl or Brigid Bohl.

Effective date of this notice is March 1, 2009.

Our pledge regarding medical information:

Make sure that protected health information about you is kept private;

Give you this notice of our legal duties and privacy practices with respect to protected health information about you; and

Follow the terms of the notice that are currently in effect.

How we may use and disclose medical information about you:

For treatment. We may use protected health information about you to provide for medical treatment or services in our office. We may disclose medical information about you to other doctors, nurses, technicians, or hospital personnel who are involved in taking care of you at the hospital or in other doctor’s offices. We may disclose protected health information about you to other people outside our office who may be involved in your medical care such as family members, laboratory technicians, or health professionals outside our office who are involved in your care.
For payment. We may use and/or disclose protected health information about you so the treatment and services you receive may be billed to and payment may be collected from you, an insurance company, or a third party. We may send you a statement for our services that contains our return address on the envelope. We may also tell your health plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
For health care operations. We may use and/or disclose protected health information about you for business purposes of our practice. These purposes are activities such as assuring quality care for our patients and evaluating the performance of our staff. We may also share your protected health information with others who assist us in record keeping and billing.
Appointments and reminders. We may use and/or disclose protected health information to contact you or as a reminder that you have an appointment, to keep track of who is waiting in the office to be seen, and to call your name in the reception area.
Emergencies. We may also use and/or disclose protected health information about you for emergency treatment This could occur in a situation when you have come into our office and are unable to provide consent because of the condition of your health and the need for immediate treatment. If this happens, we will attempt to obtain your permission for this use or disclosure as soon as possible following the emergency treatment.
Individuals involved in your care or in payment for your care. We may disclose protected health information about you to a friend or family member who is involved in your medical care or who is involved in the payment for your care.
For communication purposes. We may use and/or disclose protected health information about you to a third party if we have significant difficulty communicating with you. For example, if you have difficulty understanding English or if you are deaf, we may wish to have an interpreter assist us in communicating with you.
Business associates. We may disclose protected health information to employees in other businesses who assist us in your health care treatment. When we use business associates to assist us in providing service to you, we require that they agree to safeguard your protected health information before we allow them to be our business associates and before we disclose any protected health information to them.
Correctional institution. We may disclose protected health information about you to individuals in correctional facilities so that you can receive appropriate care if you go to jail.
As required by law. We may disclose protected health information about you when required to do so by federal, state, or local law. If a law requires that we disclose protected health information about you, we will do so only to the extent required by law. Federal law permits and requires us to disclose your protected health information to agencies that do healthcare oversight, public health activities, workers compensation, food and drug administration, and similar legally registered activities. For example, state law requires that we report instances of communicable diseases, such as venereal disease, to the Health Department. Another example is if a drug or any other product prescribed to you has been recalled by the Food and Drug Administration, we may be required to disclose your name and identifying information to them.
Lawsuits, disputes, and subpoenas. If you are involved n a lawsuit or dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law enforcement. We may disclose protected health information about you if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, missing person, or material witness; about the victim of a crime under certain limited circumstances; in emergency circumstances to report a crime.

Your rights regarding health information about you

Right to inspect and copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to us no later than one week before you would like to inspect your protected health information. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect or copy in certain very limited circumstances. If you are denied access to protected health information about you, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
Right to amend. If you feel that protected health information that we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the practice. To request an amendment, your request must be submitted to us in writing. In addition, you must submit a reason that supports your request. We may deny your request if: the information in question was not created by us; the information in question is not part of the protected health information kept by or for the practice; the information in question is not information that you would be permitted to inspect or copy; or the information in question is accurate and complete. If we deny your request for the amendment, we must let you know in writing. You have the right to disagree with our denial of your requested amendment.
Right to an accounting of disclosures. You have the right to request that we provide you with and accounting of disclosures in compliance with 45 CFR 164.528. This is a list of certain disclosures that we have made of your protected health information that were not related to treatment, payment, health care operations, or any other of the routine uses or disclosures described in this Notice, were not required by law, and for which you did not sign an authorization. To request this list or accounting of disclosures, you must submit your request to us in writing. Your request must state a time period, which may not be longer than 6 years. The first list that you request in any 12 month period will be free. For additional lists we may charge you the costs associated with producing the list. We will notify you of the cost and you may choose to modify or withdraw your request at that time before costs are incurred.
Right to request restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have a right to request a limit on the protected health information that we disclose about you to someone who is involved in your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request to us in writing. In this request, you must tell us what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.
Right to request alternative communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we communicate with you at work or by mail. To request confidential alternative communications, you must make your request to us in writing. We will accommodate all reasonable requests.
Right to a paper copy of this notice. You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

Changes to this notice:

Complaints:

200 Independence Avenue S.W., Washington, D.C.

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other uses of medical information:

Patient Acknowledgement Form

Notice of Privacy Practices

____ I have received a copy of Privacy Practices from R. Daniel Bohl, Urologist.

Patient‘s Name:________________________________ DOB:_____/_____/_______

Patient’s Signature:_____________________________ Date:_____/_____/_______

____Patient declined the notice of Privacy Practices from R. Daniel Bohl, Urologist.

Staff signature:_____________________________

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Ways In Which We May Communicate With You:

1) May we leave messages at your home? Yes No

2) May we leave messages at work? Yes No

3) May we leave messages on your answering machine at home? Yes No

4) May we leave messages on your voicemail? Yes No

5) May we mail information to your home address? Yes No

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I understand that it is my responsibility to notify R.Daniel Bohl, Urologist in writing if I want to make changes to the above requests.

Patient’s Signature:____________________________________

R. Daniel Bohl MD

Urologist

Consent to Allow Disclosure of Protected Health Information

You may wish to give us permission to share your protected health information with certain individuals such as your spouse or your children. This form serves to give us that permission.

Name Relationship

____________________________ _______________________________

_____________________________ _______________________

Patient signature Date

_____________________________

Witness