Family Practice Questionnaire

xx/xx/xxxx
xx/xx/xxxx
DRUG NAME, STRENGTH, FREQUENCY
Date and Location of Testing
Surgery/Reason/Year/Hospital
HIPAA PRIVACY POLICY CLICKACLINIC.COM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. A. PURPOSE OF THIS NOTICE CLICKACLINIC.COM, INC. (“CAC”) is committed to preserving the privacy of your health information. In fact, we are required by law to do so for any health information created or received by us. CAC is required to provide this Notice of Privacy Practices (“Notice”) to you. The Notice tells you how we can and cannot use and disclose the health information that you have given to us or that we have learned about you when you were a patient in our Online Telemedicine system. It also tells you about your rights and our legal duties concerning your health information. CAC is required to abide by this Notice and any future changes to the Notice that we are required or authorized by law to make at all CAC locations, including any medical facilities open to the public that CAC may operate both in Florida and in other states, any primary care and specialty clinics; psychiatric medical facilities or facilities offering psychological counseling services, and community service and outreach programs. This Notice applies to the practices of: • All CAC employees, volunteers, service providers, including clinicians, who have access to health information. • Any health care professional authorized to enter information into your CAC health record. • Any non-CAC clinicians who might otherwise have access to your health information created or kept by CAC, as a result of, for example, their call coverage for CAC, or CAC customer facilities and their employed physicians and clinicians. For the rest of this Notice, “CAC,” we” and “us” will refer to all services, service areas, and workers of CAC. When we use the words “your health information,” we mean any information that you have given us about you and your health, as well as information that we have received while we have taken care of you (including health information provided to CAC by those outside of CAC). We will have a copy of the current Notice with an effective date in clinical locations and on our website at HIPAA Privacy Policy. You have given us permission to send you SMS and email messages and notifications without restriction.
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