1. health and fitness
2. disease
3. cancer

SOuTHERN
UROLOGY
Martin J. Ducote, M.D.
Christopher P. Fontenot, M.D.
BEAULLIEU DR,, BUILDING #7
LA,FAYETTE, LOUISIANA 70508
TELEPHONE Q37) 232- 4s s 5
FAX (337) 232-0906
OFFICE EMAIL: NIWIj LITFIA U4C@GN'LdTI-.C()I'I
2OO
COMPLETELY fill out the attached packet of information and
either FAX , MAIL or EMAIL to our office before your scheduled
Please
appointment.
access to a fax machine and time will not allow for the
packet to be mailed, please arrive at our office at least 20 minutes prior to
your appointment time to complete all necessary paperwork. Failure to
provide the requested information ahead of time may result in your
If you do not have
appointment being rescheduled by our office.
Our office assumes the right to reschedule any patient that is 15 minutes late
for their scheduled appointment time.
Upon arrival to our office you will be asked to submit a urine specimen
prior to seeing the doctor (this will be required for all office visits).
It is the patient's responsibility to provide our office with all pertinent
previous medical records (lab results, ultrasounds, scans etc). Please contact
your previous/referring doctor to make sure that all records are faxed, mailed
or emailed to our office BEFORE your scheduled appointment. If records
are not received in time, your appointment will be rescheduled.
Having this information ahead of time will GREATLY assist our office in
seeing you for your appointment in a timely and efficient manner' Your
cooperation in this matter is most appreciated.
Thank You,
Drs. Ducote and Fontenot
MARTIN J, DUCOTE, M.D. AND CHRISTOPHER P. FONTENOT, M.D.
Age:
Referring Doctor:
Date:
Patient Namc:
Address:
Zip
code
May we contact you by e-mail o
E-mail address:
Sex:
State
City
Strect or P. O. Box
YES o
Social Security #:
Date of birth:
#:
Cell #:
City
State
Work Phone
Home Phone #:
Employcr:
Employer Addrcss:
Street or P.O. Box
Occupation:
Employer Telcphonc #:
Race
Hispanic
o
Non Hispanic a
Language: English
o
Other
Namc of person lcgally responsible for the bill:
(if minor give name of parent, guardian, etc.)
Phone #:
Whom may we contact in case of an emergency?
Phone #:
Nearcst rclativc not living with you:
INSURANCE INFORMATION
Are you on Mcdicarc? o Ycs
o No
Railroad Medicare? o Yes
Is Medicare your [i1q1.11 insurance? o Yes
I No
o
No
Medicare #:
OTHER INSURANCE INFORMATION
Name of Insurance Company:
Telephone #:
Address:
Policy Holder's DOB
Policy Iloldcr's Namc:
Policv Holder's SS#:
Policy I{older's Employer
Policy #:
Group #:
Zip code
No
DUCOTE & FONTENOT, PMC
WRITTEN ACKNOWLEDGEMENT OF PJCEIPT OF PRIVACY PRACTICES
I HAVE RECETVED A COPY OF DUCOTE & FONTENOT, PMC NOTICE OF PRIVACY
PRACTICES.
PATIENT NAME (PLEASE PRINT)
LEGAL GUARDIAN TPLEASE PRINT)
SIGNATURE OF PATIENT/LEGAL GUARDIAN
DATE
ASSIGNMENT OF INSURANCE BENEFITS
I REQUEST PAYMENT OF BENEFITS DIRECTLY TO DUCOTE & FONTENOT, PMC.
I GUARANTEE PAYI\4ENT OF ANY AMOI,NTS NOT PAID BY N,fY INSURANCE CARRIER
FOR CHARGES INCURRED IN THE TREATMENT OF THE PATIENT.
PATIENT NAME (PLEASE PRINT)
LEGAL GUARDIAN (PLEASE
PRINT)
SIGNATURE OF PATIENT,iI,EGAI GUARDIAN
DATE
CONSENT FORUSE AND DISCLOSI]RE OF PROTECTED HEALTH INFORMATION
I IIEREBY GIVE CONSENT FORDUCOTE & FONTENOT, PMC TO USE AND DISCLOSE
PRIVATE }IEALTHCARE INFORMATION ABOUT ME TO CARRY OUT TREATMENT,
PAYMENT AND T{EALTHCARE OPERATIONS. REFER TO DUCOTE & FONTENOT, PMC
NOTICE OF PNVACY PRACTICES FOR A MORE COMPLETE DESCRIPTTON OF SUCfi USES AND
D]SCLOSURES
THIS CONSENT IS VAIID IINTIL REVOKED IN WRITING. IF I DO NOT SIGN THIS CONSENT, OR
LATER REVOKE IT, DUCOTE & FONTENOT, PMC MAY DECLINE TO PROVIDE TREATMENT TO
ME,
PATIENT NAME (PLEASE PRINT)
LEGAL GUARDIAN (PLEASE PRINT)
SIGNATURE OF PATIENT/LEGAL GUARDIAN
DATE
SourHe nxt
UROLOGY
OFFICE OF CHR,SIOPHER FONIENOI, M.D. ond MARLN "ZEKE" DUCOTE, M.D.
PATIENT NOTIF'CAI'ON OF OUR F'NANC'AI.
POI'CY
Southern Urology is commilied 1o providing ihe highest quolily of heolthcore ovoiloble
while mointoining o finonciol policy thol is foir-ond in some coses flexible-lo our
poiienls. Firsl ond foremosl, it importont foryou lo underslond lhot, regordless of your
insuronce stolus, you ore ultimolely responsible for poyment of your occount.
We occept cosh, checks, ond mojor credit cords. We olso now occepl CoreCredit (for
more informolion, see boltom section, below). We occept Medicore ossignment ond
ore porticipoting providers for mony monoged core plons. We ore obligoted to follow
their guidelines reloled lo billing, colleciions ond ollowoble pricing on "covered"
services. However, eoch policy is wrilten differently ond il is lhe potient's responsibility
to be owore of whot lheir own policy does ond does nol cover. Some oiher key poinls
io know:
we ore "porticipoting providers" with your insuronce compony, we will collect copoys, deductibles, co-insuronce ond other oul-of-pocket expenses your insuronce
compony does nol cover ol the time of service.
o For our privoie poy polients, we offer o 25% discouni when poying in full ot iime of
service.
. For privole poy potients ond those with insuronce plons wilh whom we do not
poriicipote, the poyment is due ol the lime of service. We do nol file cloims to
insuronce componies with whom we do noi porticipole; ihis is the potient's
responsibilily.
. lf the ossignmeni of benefits is rejecled or if your insuronce foils lo poy on o cloim
occording to our conlroctuol terms within 50 doys ofler it hos been filed, it will be your
responsibility io poy the chorges in full.
. We send stotements ond bills to polients on unpoid omounts owed. At the
discrelion of our billing deportment, we moy ogree upon certoin poyment
onongemenls. However, locking ony ogreed-upon poyment orrongemenl wilh you
(or foiling io moke poyment on such ogreed-upon omounl) we moy turn your
occounl over to on outside colleclion ogency. lf ol ony time you connol poy your
bil/, pleose conloct our billing office ro discuss.
. Certoin diognostic lests moy be performed wilh required on "outside" physicion,s
professionol services (exomple: o pothologist's inlerpretotion/report on o biopsy
somple). Be owore lhot you moy receive ond seporote bill from o physicion or lob
for services not performed by Southern Urology. Pleose inquire wilh our physicion or
nurse should you hove questions obout whelher of your porliculor tests ore sent lo
outside providers.
o lf
SOUTIIF.RN
UROLOGY
F'NANC'AL POL'CY
OFFICE OF: CHRISIOPHER P. FONIENOT, MD & MARLN "ZEKE" DUCOTE MD
PATIENT NOT'FICAT'ON OF
. you moy be referred to certoin senvices (diognostic cT, rodiotion oncology. certoin
lob testing) ot Lofoyelte Diognostic & Rodiotion Treotment Cenier. This focility is port
of the Southern Urology. wholly owned ond port of our Group Proctice. Bills for these
tests will come from Soulhern urology, but show os o seporote proclice locolion.
. Dr. Fontenol is o finonciol porlner ond/or hos o finonciol interest in Lofoyeile Surgicol
Speciolty Hospiiol, Southern Llthotripsy, LLC ond southern Loser, LLC. Al some point
iuring your core under Dr. Fontenot or Dr. Ducote, you moy be referred to receive
services by one of these entities.
. Non-Medicol chorges: speciol medicol forms ond record copying is chorged ol o
vorioble roie depending on number of poges. $50 is chorged on oll NSF checks.
CARECREDIT
we con no longer corry occounts over 90 doys posi due in our office. we hove been
informed thot our cPA will be loking over oll delinquent occounts os of Seplember 1
2012. Fortunotely, we now offer o Heolthcore credit cord colled corecredit.
Corecredil ollowi you lo "sirelch" your poyments ond is occepted ot more thon
l5o,ooo enrolled heolthcore proctices such os dentist, veterinory clinics, eye clinics,
heoring oids ond chiroproclic core. Some feotures ore:
.
oAlineofcreditconbeesloblishedondopprovoltokes5minutesinour
o
o
o
off
ice
There is no onnuol fee ond no iniiiol down poyment required
You con opply in our office or by going online lo www corecredit'com
We offer 6 months interest free finoncing on most chorges
These finonciol options will meet the needs of mosl every fomily in our proctice. we
hove lislened to your concerns ond hove mode greot effort lo respond to lhose
concerns. Thonk you for your continued support.
By signlng betow, I ceifi lhot t hove reod lhis Finonciol Policy ond understond ils terms
ond condirions.
Signolure of Potienl / Responsible Person:
Prinled Nome of Polient/Responsible Person:
Dole:
Patient Name:
Date of Birth:
Pasf.MedicatHislory: Check boxes EI of all conditions you are diagnosed with.
Cardiovascular
!
C
E
!
E
tr
!
Anemia
Aneurysm
Arrhythmia (lrregular Heart Beat)
Atrial Fibrillalion (AFib)
Congestive Heart Failure (CHF)
DVT (Blood Clot)
High Blood Pressure (Hypertension)
Mitral Valve Prolapse
Sickle Cell Anemia
fl
tr
! Other:
Endocrine
E Diabetes E lnsulin E Non-lnsulin
D
tr
D
C
Hypogonadism (Low Testosterone)
Gout
Thyroid tr Hyper- tr HypoOlher:
General
High Cholesterol
Obesity
tr
tr
Gastrointestinal
E Gallstones
! Chrons' Disease / Colitis
E Diverticulitis
tr Hepatitis, Type _
E lrritable Bowel Syndrome
E Pancreatitis
E Stomach Ulcer
! Other:
Genitourinary
tr AIDS / HIV
tr
!
!
E
E
E
D
BPH
Epididymitis
HPV
lmpotence
lnterstitial Cystitis
Kidney Stones
Polycystic Kidney Disease
Prostatitis
n
n Other:
Head, Ears, Eyes, Nose, Throat
tr Blind
E Cataracts
! Deafness
E Glaucoma tr Open Angle tr Closed
D
D
Sinusitis
Tinnitus (Ringing in ea(s))
Musculoskeletal
n Arthritis
!
E
E
[]
Carpel Tunnel
Fibromyalgia
Osteoporosis
Other;
Neuro/Psych
tr
E
C
E
tr
!
tr
!
E
!
tr
tr
tr
ADD
Alcoholism
Alzheimer's Disease
Anxiety
Bipolar Disorder
Depression
Multiple Sclerosis
Parkinson's Disease
Seizure Disorder
Spina Bifida
Spinal Cord lnjury
Stroke (CVA)
Other:
Respiratory
D Asthma
E Bronchitis
tr COPD
E Emphysema
E Pneumonia
E Pulmonary Emboli (Blood Clot in Lung)
E Sleep Apnea
trTB
fl
Other:
Tumors / Cancer
! Bladder Cancer
El Brain Tumor
E Breast Cancer
! Cervical / Uterine Cancer
E Colon Cancer
E Lung Cancer
E Lymphoma
E Ovarian Cancer
E Pancreatic Cancer
C
E
E
!
E
E
!
E
Prostate Cancer
Rectal Cancer
Renal Cancer - Kidney
Sarcoidosis
Skin Cancer
Stomach Cancer
Testicular Cancer
Throat Cancer
Ex h-P/*,.,.t
SEEfrophvlaxis
Do you have to take antibiotics prior to dental or surgical procedures due to a heart condition?
tr No tr Yes. lf yes, please specify
SexuatHisions
Are you sexually active?
Multiple Partne(s)
lf yes, tr Single or
Birth Control E None
!
tr
E
n
Birth Control Pill
Condom / Diaphragm
Other:
OEJGY[Hislotrr
Last Menstrual Period
Age of 1"t Period
Do you have regular periods?
Prior Abnormal Pap Smear?
Age of Menopause.
trNo
Pregnant Now: E Yes
Number of Pregnancies
Number of Deliveries
#Full Term Deliveries
#Premature Deliveries
#Vaginal
Sexually Transmitted Disease
O None
E Gonorrhea
!
i
!
Syphilis
Herpes
HPV / Genital Warts
Have you had a hystereclomy?
!
E
!
E
Partial (still have ovary or ovaries)
Complete
Vaginal
Abdominal incision
Deliveries
#C-Section Deliveries
EamilvXistqlt:
Does anyone in your family have the following conditions?
Are you adopted? tr Yes D No
Write in if your rn other, father, grandmother, grandfather, brother, sister, aunt, uncle have any of the
following conditions.
BPH (Enlarged Prostate)
Bedwefting
Bladder Cancer
Breast Cancer
Cervical Cancer
Colon Cancer
COPD (lung disease)
Diabetes
Heart Attack
High Blood Pressure
Kidney Cancer
Kidney Disease (What type?)
Kidney Stones
Lung Cancer
Ovarian Cancer
Pancreatic Cancer
Parkinson's
Prostate Cancer
Stroke
Uterine Cancer
Other:
Patient Name:
Date of Birth:
Socialltislory
Marital Status
E
fl
D
tr
E
Married, how tong?
Single
Divorced
Widow
Life Partner, how long?
Children E Yes E
No
lf yes, how
manY?-
Occupation
Alcohol Consumption
Do you drink alcohol?
what?
No
D
Occasionally / Socially
! Daily, How many?.
El Beer
Wine
tr Liquor
lf yes, how often?
lf yes,
E Yes E
!
Smoking History
Do you currently smoke?
D Yes tr
No
lf yes, how many packs a daY?
How many years have you smoked?
Do you use smokeless
tobacco?
tr Yes trNo
Did you smoke in the past? EYes
How many packs a day?
How many years did you smoke?
How long ago did you quit?
Drug Use
Do you use recreational drugs?
lf yes, what type?.
!No
tr Yes E
No
Caffeine
Do you drink caffeinated beverages?
E Yes D
No
lf yes, what type?
How many (cups, cans, etc) a day?
Foreign Travel
Have you traveled to a foreign country recently?
lf yes, where?.
!
Yes tr
No
Patient Name:
Date of Birth:
How Manv/Much?
Pharmacy Name AND Location (Ex. M/t **,, /,k"t""
& '9,,il C,$,r)
Do you need 90-day prescriptions to mail order?
Primary Care Physician (Ex.
0..
&. C"',!)
!
Yes tr No
SOTJTHERN
URO[-OGY
Martin J. Ducote, M.D.
Christopher P. Fontenot, M.D.
BEAULLIEU DR, BUII,DING #7
I-{FAYETTE, LOUISIANA 70508
TELEPHONE (337) 232-4s55
2OO
FAX (337) 232-0906
In our efforts to mainta.in the highest quality of patient care, Drs. Ducote and Fontenot are
embarking on a new innovation in healthcare. This process is Electronic Medical
Records. To ensure protection of your privacy rites and better coordinate care with other
physicians, this process allows us to go paperless.
Initially, this can be a very timely ptocess and we want to apologize for any
inconvenience this will cause you. ln every effort to expedite your visit, we will collect
yonr copay or coinsurance in advance based on the anticiPated charges. Final billing will
be contingent upon the doctor's completed chart note. Any discrepancies will be
resolved in a timely marmer resulting in a possible refund or additional bill sent to you at
a later date.
Again, we have implemented this process as an effort to keep up with advancing
technology available to us. Your cooperation during this process ts GREATLY
appreciated. If you feel the need to discuss the above firrther, please feel free to speak
with our practice manager, Michelle Buteau.
Thank You,
Drs. Ducote and Fontenot
,-
-i
Effect Date of this Notice: 41212003
Revised Date: 91612012
Southern Urology
Martin J. Ducote, M.D.
Christopher P. Fontenot, M.D.
Notice of Privacy Practices
As required by the Privacy Regulations Created as a Resuit ofthe Health Insurance Portability and
Accountability Act of 1996 (HIPPA)
TIIIS NOTICE DESCRIBES HOW HEALTH INT'ORMATION ABOUT
YOU (AS A PATIENT OF'TTIIS PRACTICE) MAY BE USED AND
DISCLOSED A}{D HOWYOU CAN GET ACCESS TO YOT'R
INDIVIDUALLY IDENTIFIABLE HEALTH INT'ORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
A. OUR COMMITMENT TO YOTJR PRIVACY
Our practice is dedicated to maintaining the privacy ofyour individually identifiable health
information (IIHI). In conducting our business, we will create records regarding you ald the
treatrnent 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 conceming your IIHI.
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
fol l owing important infonnation:
How we may use and disclose your IIHI
Your privacy rights in your IIHI.
Our obligations conceming the use and disclosure of your IIHI
The terms of this notice apply to all records containing your IIHI that are created or retained
by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any
revisions 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 ofyour 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.
.
.
.
B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:
Michelle Buteau
200 Beaullieu Drive Bldg #7
Lafayette LA 70508
337-232-455s
C. WE MAY USE AND DISCLOSE YOUR INDTVIDUALLY IDENTIFIABLE HEALTH
INT'ORMATION (IIHD IN THE FOLLOWING WAYS:
The following categories describe the different ways in which we may use aad disclose your IIHI.
ask you to have
laboratory tests (such as blood or urine tests), al1d we may use the results to help us reach a
1.
Treatment, our practice may
use your
IIHI to tleat you. For example, we may
diagnosis. We might use your IIHI in order to write a
your IIHI to a pharmacy when we order a prescription
our practice, including, but not limited to, our doctors
order to treat you or to assist others in your treatment'
.r,ih your spouse, children or parents. Finally, we may also
oth"., *ho may assist in yo*
"*",
to your treatrnent.
disclose your IiHI to other health care providers for purposes related
to
bill and collect payment for the
order
your
in
IIHI
2. paymlnt, Our practice may use anddisclose
contact your health insurer to
services and itemi you may receive from us. For example, we may
vide vour
;;rfy;h" y"; are eligible for benefits (and
ay
for' your
insurer witfr aetails reg-arding your treatment
that
may be
treatment. We also may use and disclose yow
your IIHI to bill you directly
responsible for such coits, such as family members. Also, we may use
providers and entities to
for serrrices and items. we may disclosi your IIHI to other health care
assist in their billing and collection efforts'
our business'
i. Health Care Operations, Ow practice may use and disclose your IIHI to operate operations,
ow
disclose your information for our
costto
conduct
us,
or
from
you
received
of care
ru practice. We may disclose your IIHI to other
health care oPerations.
your IIHI to contact you and
4. Appointment Reminders. our practice may use and disclose
remind you of an aPpointment.
you of potential
or ditioos. o,r practice may use and disclose your IIHI to inform
!.
teatment options or alternatives.
your IIHI to inform
6. Health-itelated Benefits and Services. Our practice may use and disclose
you of health-related benefits or services that may be of interest to you'
that
R"l"r." of information to family. Our practice may release your IIHI to a family member
is involved in yow care, or who assists in taking care ofyou'
when we are
i-, nir"to.o.". Required By Law. our practice will use and disclose yow IIHI
required to do so by federal, state, or local law'
*
for
to
II
-
ii""t-""t
i.
D.UsEAI\DDIscLosUREoFYoURIIHIINCERTAINSPECIALCIRCI.IMSTA}{CES
your
fft" foUo*ing categories describe unique
scenarios in which we may use or disclose
identifi able health information:
l.PublicHealthRisks.ourpracticemaydiscloseyourllHltopublichealthauthoritiesthat
purpose of:
are authorized by law to collect information for the
Maintaining vital records, such as births and deaths
.
.
o
Reporting child abuse or neglect
Preventing or controlling disease, injury or disability
.NotifyingapersonregardingpotentialexPosuretoacommunicabledisease
. Notifiing a person regarding a potential risk for spreading or contracting a disease or
.
.
condition
Reporting reactions to drugs or problems with products or devices
N&fying individuals if a product or device they may be using has been recalled
.
Notirying appropriate govemment agency (ies) or authority(ies) regarding the potential
abuse or neglect of an adult patient (including domestic violence); however, we will only
disclose this information if the patient agrees or we are required or authorized by Iaw to
disclose this infomration.
o Notifuing your employer under limited circumstances re'lated primarily to workplace
injury or illness or medical surveillance.
2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight
agency for activities authorized by law. Oversight activities can include, for example,
investigations, irspections, audits, surveys, licensure and disciplinary actions; civil, administrative,
and criminal procedures or actions; or other activities necessary for the government to monitor
govemment programs, compliance with civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceeding. Our practice may use and disclose your IIHI in response
to a court or administrative order, if you are involved in a Iawsuit or similar proceeding. We also
may disclose your IIHI in response to a discovery request, subpoen4 or other lawful process by
another party involved in the dispute, but only if we have made an effort to inform you of the request
or to obtain an order protecting the information the party has requested.
4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official
. Regarding a crime victim in certain situations, ifwe are unable to obtain the person's
agreement
Concerning a death we believe has resulted from criminal conduct
Regarding crirninal conduct at our offices
In response to a warrant, summons, court order, subpoena or similar legal process
To identifyAocate a suspect, material witness, fugitive or missing person
In an emergency, to report a crime (including the location or victim(s) of the crime, or
the description, identity or location of the perpetrator.
Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to
identifu a deceased individual or to identift the cause of death. If necessary, we also may
release hformation in order for funeral directorc to perform their jobs.
Organ and Tissue Donation. Our practice may release your IIHI to organizations that
handle organ, eye, or tissue procuement or transplantation, including organ donation banks,
as necessary to facilitate organ or tissue donation and hansplantation if you are an organ
donor.
Research. Our practice may use and disclose yow IIHI for research purposes in certain
limited circumstances. We will obtain your written authorization to use your IIHI for
research purposes except when an Institutional Review Board or Privacy Board has
determined that the waiver of your authorization satisfies the following: (i) the use of
disclosure involves no more than a minimal risk to yow privacy based on the following: (A)
an adequate plan to protect the identifiers from improper use and disclosure; (B) an
adequate plan to destroy the identifiers at the earliest opportunity consistent with the
research (unless there is a health or research justification for retaining the identifiers or such
retention is otherwise required by law): and (C) adequate *ritten assurances that the PHI
will not be re-sued or disclosed to any other person or entity (except as required by law) for
authorized oversight or the research study, or for other research for which the use or
disclosure would otherwise be permitted; (ii) the research could not practicable be
conducted without the waiver; and (iii) the research could not practicable be conducted
without access to and use ofthe pHI.
o
.
.
o
.
5.
6.
7.
Serious threats to Health and Safety. Our practice may use and disclose your IIHI when
necessary to reduce or prevent a serious threat to your health and safety or the health and
safety of another individual or the public. Under these circtunstances, we will only make
disclosures to a person or organization able to help prevent the threat
9. Military. our Practice may disclose your IIHI if you are a member of the U.S. or foreign
military forces (including veterans) and ifrequired by the appropriate authorities10. National Security. Our practice may disclose your IIHI to federal of[rcials for intelligence
your IIHI to
and national security activities authorized by law. We also may disclose
heads of state, or
foreign
or
officials
other
federal officials in order to protect the President,
to conduct investigations.
11. Inmates. Our prictice may disclose your IIHI to correctional institutions or law
enforcement officials ifyou are an inmate or under the custody of a law enforcement
ofticial. Disclosure for ihese purposes would be necessary; (a) for the institution to provide
(c) to
health care services to you, (b) for the safety and security of the institution, and /or
8.
protectyourhealthandsafetyorthehealthandsafetyofotherirrdividuals.
12. Workers' Compensation. Our practice may release your IIHI for workers' compensation
and similar programs.
E. YOURRIGHTS REGARDING YOUR
II
you;
You have the following rights regarding the IIHI that we maintain about
that
our practice
Confidential Communicatiotrs. You have the right to request
or at a
communicate with you about your health and related issues in a particular manner
work'
than
you
rather
at
home,
we
contact
certain location. For instance, you may ask that
to
written
request
a
ln order to request a type of confidential communication, you must make
location
Michelle Butlau 337 iIZ-CSSS specifying the requested method ofcontact, or the
A
requests.
reasonable
where you wish to be contacted. our practice will accommodate
reason for your request is not needed'
to request a restriction in our use or disclosure
care operations. Additionally, you have the
e of your IIHI to only certain individuals
ur care, such as family members and friends We
to agree to your request; however, if we do agree' we are bound by ow
are not required
-except
whe,i otherwise required by law, in emergencies, or w1,en the information
agreement
use or disclosure ofyour
is necessary to treat you. IN order to iequest a restriction in our
337 232-4555' Your
Buteau
g to Michelle
e fashion:
l.
our practice's use, disclosure or both; and
but not including psychotherapy notes' Y
your
Buteau 337 :4;r-4555 in ordei io inspect and /or obtain a copy of
IIHI.
Our practice
maychargeafeeforthecostsofcopying,mailing,laborandsuppliesassociatedwithyour
."qu".t. 6* pru"tice may deny your request to inspect and /or copy in certain limited
4.
iicensed health
circumstances; however, you may request a review of our denial' Another
care professional chosen by us will condrrct revi"Yt'
.
you believe it is incorrect
Amendment. You may ask us to amend your health information if
is kept by
oi ioco.pl"t", and you may request ar amendment for as long as the information
.
orforourpractice..Torequestanamendment,yourrequestmustbemadeinwritingand
reason-that
submittedio Michelle Buieau 337 232-4555. You must provide us with a
fail to
ifyou
your
request
,"pfon, your request for amendment. our practice will deny
g your request) in writing. Also, we may deny
on that is in our opinion: (a) accurate and
r the practice; (c) not part of the IIHI which
r (d) not created by our practice, unless the
n is not available to amend the information'
5.AccountingofDisclosures.Allofourpatientshlvethlrighttorequestan:,,accountingof
our
disclosures." An "accounting ofdiscl0sures" is a list of certain non-routine discloswes
s purposes'
practice has made ofyour IIHI for
to be
Use of your IIHI as part of the
billing
Jocumented. For example, the doctor
..r.ing your information to file yow hsurance claim. In order to obtain an
J"pu.t-"rrt
aciounting of dii"ior*"., you must submit your request in writing to Michelle Buteau
a time period,
331 232-[SSS, All requests for an "accounting ofdisclosures." must state
which may not be longer than six (6) years from the date of disclosure and may not include
period is free of
dates before April 14, 2003. The first list you Iequest within a 12 month
12 month period'
the
same
charge, but oui practice may charge you for additional lists within
and you may
Our iractice wiil notify you of the costs involved with additional requests,
withdraw your request before you incru any costs'
e a paper copy of our
Right to a Pape. Copy of This
this notice at any time To
noii"" of privacy praciices. Yot, may
232-4555'
obtain a paper copy of this notice contact
violated, you may
night to File a Cimplaint. If
of Health and
filJa complaint with our practice
Buteau at 337
Human Services. To file a complaint with
232-4555. All complaints musibe submitted in writing. You witl not be penalized for
filing a comPlaint.
will
Righ"t to Provide an Authorization for other uses and Disclosures. our practice
notice
obiain your written authorization for uses rd disclosures that are not identified by this
and
use
the
regarding
your
provide
to
us
or permitted by applicable law. Any authorization
your
you
revoke
disclosure of your IIHI may be revoked at any time in uriting. After
authorization, we will no longer use ofdisclose your IIHI for the reasons described in the
authorization. Please note, we are required to retain records of your care
non
routine
sharin
6.
7
.
8.
Notice.
as
M
you
o
o
Again, if you have any questions regarding this notice or our health information privacy policies,
please contact Michelle Buteau at 337 232-4555.