|New Patient Privacy Forms|
Northern Virginia Area Bariatric Consultants Privacy Practices
This notice describes the way in which medical and personal information pertaining to you may be used and disclosed. It also, explains how you can access your health information. Please review it carefully and sign the attached acknowledgement receipt at the bottom of this notice and return it to the receptionist.
At Northern Virginia Area Bariatric Consultants the staff is committed to the protection of your private health information. Within our office access to your information is limited to those employees who need access in order to perform their jobs.
Northern Virginia Area Bariatric Consultants may use and disclose protected health information in order to facilitate treatment, collect payments and for internal healthcare operations. Examples of these include, but are not limited to referral to other healthcare providers, life insurance physicals, and home healthcare agencies. Payment examples include your health insurance provider for claims and coordination of benefits, workman's compensation or similar programs: Collections agencies, etc. Healthcare operations include auditing of records and internal quality control.
Northern Virginia Area Bariatric Consultants is required by law to use and/or disclose protected health information without the patients' written consent or authorization in certain circumstances. These include reporting a crime, responding to a subpoena, warrant or court order; public health officials concerned with controlling disease, disability and injury.
Northern Virginia Area Bariatric Consultants may use or disclose protected health information to your personal representative whom you have authorized to act on your behalf in making decisions related to your health care.
NOVA ABC Weight Loss Clinic will contact patients at phone numbers provided to us by the patient in order to give appointment reminders or other information regarding treatment and/or tests results.
NOVA ABC Weight Loss Clinic will not use or disclose a patients protected health information as is described in this notice without the individual's written authorization. This authorization may be revoked at any time in writing. Exceptions are those described above as required by law.
NOVA ABC Weight Loss Clinic will abide by this notice which is currently in effect as of April 14, 2003, at the time of disclosure. We reserve the right to revise the terms of this notice and make new provisions effective for all protected health information we maintain.
NOVA ABC Weight Loss Clinic will keep a posted copy of our current privacy practices in our lobby area. Copies of this notice may also be obtained at any time in our office.
Any person/patient, who believes their privacy rights have been violated, may register a complaint with our office manager at 703-494-1020; and to the Secretary of Health of Human Services.
It is our office policy that no retaliatory action will be made against any individual who submits a complaint of non-compliance of the privacy standards
You have the legal right to inspect copies of your protected health information. This requires a written, signed and dated request. (as allowed by State law, reasonable copy fees may apply)
If you believe your health information is inaccurate or incomplete, you may request to amend your information. In the event that we deny your request, we will inform you of our reasons for such a denial in writing.
You have the legal right to request restrictions on certain uses of your protected health information as provided by 45CFR 154.522(a). By law we are not required to comply with a requested restriction.
Acknowledgement of Privacy Practices:
I have received a notice of privacy practices, outlining my rights regarding my protected health information and the specific ways in which my private health information may be used and disclosed as allowed under state and federal law.
Patient or legal Representative___________________________Date_____________
Relationship of above if not signed by patient_________________________________
In the event patient refused to sign________________________________________
WEIGHT LOSS CONSENT FORM
I_______________________________authorize Dr William C. McCarthy and his staff at Northern Virginia Area Bariatric Consultants to help me in my weight reduction efforts. I understand that my program may consist of a balanced diet, a regular exercise program, instruction in behavior modification techniques, and may involve the use of appetite suppressant medications. Other treatment options may include a very low calorie diet, or a protein supplemented diet. I further understand that if appetite suppressants are used, they may be used for durations exceeding those recommended in the medication package insert It has been explained to me that these medications have been used safely and successfully in private medical practices as well as in academic centers for periods exceeding those recommended in the product literature. I understand that any medical treatment may involve risks as well as the proposed benefits. I also understand that there are certain health risks associated with remaining overweight or obese. Risks of this program may include, but are not limited to, nervousness, sleeplessness, headaches, dry mouth, gastrointestinal disturbances, weakness, tiredness, psychological problems, high blood pressure, rapid heartbeat and heart irregularities. These and other possible risks could, on occasion be serious or even fatal. Risks associated with remaining overweight are tendencies to high blood pressure, diabetes, heart attack and heart disease, arthritis of the joints including hips, knees, feet and back, sleep apnea, and sudden death. I understand that these risks may be modest if I am no significantly overweight, but will increase with additional weight gain.
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that obesity may be a chronic, life-long condition that may require changes in eating habits and permanent changes in behavior to be treated successfully.
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. If you have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, ask your doctor now before signing this consent form.
Weight-Loss Consumer Bill of Rights
WARNING: Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1/2 pounds to 2 pounds per week or weight loss of more than 1 percent of body weight per week after the second week of participation in a weight loss program. Consult your personal physician before starting any weight loss program. Only permanent lifestyle changes such as making healthful food choices and increasing physical activity, promote long-term weight loss. Qualifications of this provider are available upon request. You have the right to ask questions about the potential health risks of the program and its nutritional content, psychological support, and educational components; receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations and laboratory tests; know the actual or estimated duration of the program.
I have read the above:
Release of Medical Records
I give permission for my medical records (blood work, chart, EKG) to be release to:
"BEFORE" AND "AFTER" PHOTOS
I_____________________________________, give my permission for NOVA ABC to take my "before" and "after" photographs. (photographs will not be used for advertising without patient permission)
PATIENT INFORMED CONSENT FOR APPETITE SUPPRESSANTS
I. Procedure and Alternatives:
1. I______________________________________(patient or patient's guardian) authorize Dr. William C. McCarthy to assist me in my weight reduction efforts. I understand my treatment may involve, but not be limited to, the use of appetite suppressants for more than 12 weeks and when indicated in higher doses than the dose indicated in the appetite suppressant labeling.
2. I have read and understand my doctor's statements that follow:
3. I understand it is my responsibility to follow the instructions carefully and to report to the doctor treating me for my weight any significant medical problems that I think may be related to my weight control program as soon as reasonably possible.
4. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the appetite suppressant will be dependent on my progress in weight reduction and weight maintenance.
5. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced calorie counting program or and exchange eating program without the use of the appetite suppressant would likely prove successful if followed, even though I would probably be hungrier without the appetite suppressants.
II. Risks of Proposed Treatment
I understand this authorization is given with the knowledge that the use of the appetite suppressants for more than 12 weeks and in higher doses than the dose indicated in the labeling involves some risks and hazards. The more common include nervousness, sleeplessness, headaches, dry mouth, weakness, tiredness, psychological problems, medication allergies, high blood pressure, rapid heartbeat and heart irregularities. Less common, but more serious, risks are primary pulmonary hypertension and valvular heart disease. These and other possible risks could, on occasion, be serious or fatal.
III. Risks Associated with Being Overweight or Obese:
I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies to high blood pressure, to diabetes, to heart attack and heart disease, and to arthritis of the joints, hips, knees and feet. I understand these risks may be modest if I am not very much overweight but that these risks can go up significantly the more overweight I am.
IV. No Guarantees:
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also, understand that I will have to continue watching my weight all of my life if I am to be successful.
V. Patient's Consent:
I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions I have concerning them have not been answered to my complete satisfaction. I have been urged to take all the time I need in reading and understanding this form and in talking with my doctor regarding risks associated with the proposed treatment and regarding other treatments not involving the appetite suppressants.
IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THE PROPOSED TREATMENT, OR ANY QUESTIONS WHATSOEVER CONCERNING THE PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK YOUR DOCTOR NOW BEFORE SIGNING THIS CONSENT FORM.
(can be signed by legal guardian if patient is a minor)
VI. PHYSICIAN DECLARATION:
I have explained the contents of this document to the patient and have answered all the patient's related questions, and to the best of my knowledge, I feel the patient has been adequately informed concerning the benefits and risks associated with the use of the appetite suppressants, the benefits and risks associated with alternative therapies and the risks of continuing in an overweight state. After being adequately informed, the patient has consented to therapy involving the appetite suppressants in the manner indicated above.
NOVA ABC Hours of Operation and Cancellation Policy
We make every effort to make sure your visits are pleasant and efficient for you. Please make every effort to arrive at your appointment on time. If you are unable to make your scheduled time just call and notify our office. (AFTER HOURS YOU CAN LEAVE A MESSAGE ON OUR PHONE) Or email us at email@example.com Our patient hours are as follow:
Monday 12:30 pm -7 pm
Tuesday 12:30 pm -7 pm
Wednesday 6:30 am -11:30 am
Thursday 6:30 am -1 pm
Friday 6:30 am-10 am
Phone hours are available to make appointments between 9 am - 4 pm Monday-Tuesday, 9 am - 2 pm Wednesday-Thursday and Fridays between 6:30am - 12 pm (these hours are subject to change depending on staff availability)
If you need to miss an appointment please call 24 hours in advance to cancel in order to avoid a $50.00 no-show fee. Again you can call after hours and leave a message on our answering machine. Our phone number is 703-494-1020 and press #8 to leave a message.
I ACKNOWLEDGE THE ABOVE MENTIONED NO-SHOW POLICY AND UNDERSTAND I WILL BE CHARGED $50.00 FOR FAILURE TO GIVE 24 HOURS NOTICE TO THE OFFICE OF CANCELLATION.