Hepsharat Amadi, M.D., AP - 10189 West Sample Road - Coral Springs, Florida 33065

PERSONAL INFORMATION

IF PATIENT IS A MINOR, PLEASE PROVIDE THE FOLLOWING:

EMPLOYMENT INFORMATION

IF EMPLOYED PLEASE PROVIDE THE FOLLOWING INFORMATION

REFERRAL SOURCE:

 48 HOUR CANCELLATION POLICY

All appointments must be cancelled at least 48 hours prior to the scheduled appointment date and time.  Otherwise, the full cost of the appointment will still charged. (Emergencies are an exception to this rule.) We also accept checks. If the check is returned unpaid, your signature gives us permission to debit your credit card account for the original amount, plus a return fee. Please provide your credit card information:

LIFESTYLE:

FAMILY HISTORY:

FOR WOMEN ONLY:

PAST MEDICAL HISTORY:

HISTORY:

WOMEN ONLY:

FOR MEN & WOMEN:

HISTORY OF THE PRESENT ILLNESS:

OFFICE INFORMATION AND POLICIES:

OFFICE INFORMATION & POLICIES (Please sign at each clause and at the bottom to acknowledge understanding and agreement to the following :)

Dr. Amadi carries no malpractice insurance.

By consulting Dr. Amadi, I, the patient, expressly waive my right to sue her or her office staff.

By arranging for this appointment, I the patient, recognize that Dr. Amadi will be spending her time and effort in the consultation and that there are NO claims being made by her in terms of guarantees of results, and NO refunds available for her professional fees for the consultation.

I, the patient, acknowledge that my health is my responsibility. Therefore, as someone who is interested in being as well as possible naturally, I agree to take an active role in my own treatment. I will ask questions if I do not understand things that Dr. Amadi or her office staff say to me, until the meaning of what they are trying to convey has been clarified for me. I will inform Dr. Amadi if any of the suggestions that she makes to me will be difficult for me to implement for whatever reason. I agree that my health improvement will be a team effort on the part of myself, Dr. Amadi (my consultant), and whichever other health practitioners I choose to allow to treat me.

I acknowledge that most, if not all, chronic health problems are due to lack of healthy lifestyle patterns and therefore, in order to permanently resolve my health issues for the better naturally, there are areas of my lifestyle I am going to need to change and Dr. Amadi will advise me on this.

Her Area of Expertise. Dr. Amadi has no hospital privileges. Her area of expertise is PREVENTIVE holistic medicine. Dr. Amadi will do everything she can during her consultations with me, the patient, to help me prevent emergencies from arising. For semi-urgent situations that may arise after regular office hours and/or on weekends, try calling the office phone first, especially up until 8 PM on weekdays. Leave your name and phone number FIRST, followed by a brief message, FOR TRUE MEDICAL EMERGENCIES in which a potentially life-threatening process is occurring (i.e. difficulty breathing, chest pain, hemorrhaging, etc.).  DO NOT call Dr. Amadi first. CALL 911 and get evaluated at the nearest hospital emergency room. (After calling 911, if you want to call the voicemail and leave word that you are going to a particular hospital, that would be fine, but do call 911 first).

APPOINTMENTS: At the end of each visit, Dr. Amadi will suggest when she feels it would be best for me, the patient, to be seen again. As an active participant in my own health care, I recognize that it is my responsibility to make and keep my appointments! I understand that chronic health problems need time and correct medical supervision at intervals in order to change for the better. I also understand that appointments that are not cancelled giving 24 hour notice prevent other patients from being able to avail themselves of Dr. Amadi's services, and in recognition of this, I agree to pay a fee for any appointment which is not cancelled giving 24 hour notice (except under emergency circumstances, at the sole discretion of Dr. Amadi).

PRESCRIPTIONS: As an M.D., Dr. Amadi can and does write prescriptions for medication when she feels this is needed to help stabilize a patient or manage their symptoms, until such time as more natural health care methods have a chance to work. The patient who is taking prescription medicine is responsible for knowing the names of their medications, what they are being taken for, the dosage strength-of their medicine (i.e. # of mg or mcg), and the dosing schedule (i.e. once a day, twice a day, three weeks on/one week off, etc.). In view of the fact that going off prescription medicines abruptly because they have run out can cause acute health problems, it is incumbent upon each patient who is on medications to know the status of their supply and to allow adequate time for the processing of refills. This means that you need to notify the office by at least the Wednesday prior if you want to get your prescription filled by Friday/Saturday. DO NOT WAIT until Friday afternoon to call or fax in your request because Dr. Amadi may not be able to attend to it by the time you need it.

INSURANCE: Dr. Amadi is not a participating ("in network") provider with any insurance company. She is considered an "out of network"  provider for any PPO health plan and some POS health plans. (Any patients who have an HMO will not be reimbursed by their HMO for any of Dr. Amadi's services.) Dr. Amadi does not accept Medicare or Medicaid. Insurance is a contract entered into between a patient and a given health insurance company. Dr. Amadi has not entered into any contracts with any insurance companies.

- Dr. Amadi makes no claims that any amount of her fees will be paid by any given insurance plan or company

- Dr. Amadi's office notes are for her purposes, to be able to monitor and record patient progress. Patients with insurance should understand that the insurance company has a right to request these records at any time to use as information to help them decide whether or not to pay a claim. Dr. Amadi is not willing to falsify records or keep two sets of records on a patient, one for her use and one for the insurance company. She is also not willing to falsify information as to how much was paid to her. Dr. Amadi does not participate in insurance fraud - please do not- ask her to do so.

WELCOME TO OUR FAMILY!!

PLEASE SIGN WHEN YOU ARRIVE AT THE OFFICE: _____________________________________________________

HEPSHARAT AMADI, M.D.

10189 W. Sample, Rd.

Coral Springs, FL 30645

Notice of Privacy Practices:

This Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Dear Patient:

It is our desire to communicate to you that by definition of our practice procedures, we are not legally obligated to follow these new H1PAA confidentiality laws, however, we are taking the new Federal (HIPAA - Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside of our office.

What has changed? The most significant variable that has motivated the Federal government to legally enforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it.py

How your HEALTH INFORMATION may be used. We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment and conducting health care operations, to run our practice more efficiently and ensure all our patients receive quality care, and in response to certain requests from other healthcare providers (with your express written consent (a "consent to release information form"); treatment activities or payment activities, uses and disclosures as required by law. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

To Provide Treatment. We will use your HEALTH INFORMATION to provide you with the best care possible. This may include administrative and office procedures designed to optimize scheduling and coordination of care between doctor and business office staff. In addition, we may share your health information with referring physicians, clinical laboratories, pharmacies or other health care personnel providing your treatment.

To Obtain Payment. We may include your health information with an invoice used to collect payment from you or a third party for treatment you receive in our office.

To Conduct Health Care Operations. It is possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews.

In Patient Reminders. Because we believe regular care is very important to your general health, we will call to remind you of a scheduled appointment. We will either speak with you directly or leave a message on your telephone answering machine or voice mail. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive care we can provide. They may include postcards, letters, and telephone reminders (unless you tell us in writing that you do not want to receive these reminders). Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family.

Abuse or Neglect. We will notify government authorities if we believe a patient to be the victim of abuse, neglect or domestic violence. We will make this disclosure only when we are compelled by our ethical judgement, when we believe we are specifically required or authorized by law or with the patient's agreement.

For Law Enforcement. As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Family, Friends and Caregivers. We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want, we will use our very best judgement when sharing your health information only when it is important to those participating in providing your care.

Authorization to Use or Disclose Health Information. Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights. The law is careful to describe that you have the following rights related to your health information.

Restrictions. You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

Confidential Communications. You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed. We will make every effort to honor your reasonable requests for confidential communications. Your request must specify how or where you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.

Inspect and Copy Your Health Information. You have the right to read, review, and copy your health information, including your complete chart and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information. You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. In order to standardize our process, please provide us with your request in writing and describe your reason for the change. Your request may be denied if the health information record in question was not created by our office, is not part of our records, or if the records containing your health information are determined to be accurate and complete.

Request a Paper Copy of this Notice You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time.

We will maintain the privacy of your health information and provide to you this Notice of Our Privacy Practices. We are required to practice the policies as described in this notice but we do reserve the right to change the terms of our Notice if legislation updates require.

You have the right to express complaints to us if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information directly to us.

Patient Acknowledgment of Receipt of Privacy Practices from Hepsharat Amadi, M.D.

Sign here when you come in: _______________________________________________________________

PATIENT AGREEMENT/WAIVER

I ___________________________, am aware that Dr. Amadi, as a holistic physician, is choosing to assess and treat her patients using concepts and modalities that are different from those currently considered to be the "standard of care" by most other medical doctors.

Dr. Amadi uses assessment on three levels: not only the biochemical level testing (e.g. blood tests, saliva tests, urine tests, etc.) and structural level testing (such as physical exam, X-Rays, CT/MRI scans, sonograms, etc.) but also electromagnetic assessment done using the Quantum Bio-feedback machine.

Electromagnetic testing is not currently utilized by most physicians (except in the case of the EKG, for the heart, and the EEG, for the brain). Dr. Amadi believes that the additional information that assessment on the Quantum Bio-feedback machine can provide is crucial to understanding the health of the patient on all three levels, but I acknowledge that I am aware that most physicians currently do not do this and that I choose to gather information about my health on the electromagnetic level in order to have the most comprehensive picture of my health and to give myself the greatest opportunity to improve my health and prevent disease.

I am aware that Dr. Amadi uses the Quantum Bio-feedback machine both to assess and treat patients. I understand that in Western Medicine, the definition of "treatment" of a medical condition is usually limited to taking medications and/or doing surgical procedures. Dr. Amadi uses the term "treatment" with regard to Quantum Bio-feedback to include electromagnetic balancing, optimization or harmonizing of a person's frequencies, such as is done with acupuncture or homeopathy.

I understand that the Quantum Bio-feedback machine is based on the principles of quantum physics, that say that matter and energy are two different aspects of the same thing. I also understand that a person's energy or frequencies can be accessed at a distance in real time and that this allows Dr. Amadi to test and treat a person remotely, as well as to test how a person may react to something, even though that person is not physically present in the office at the same time that Dr. Amadi is doing this.

I understand that the way Dr. Amadi prescribes bio-identical hormone replacement is different than it is often done by other doctors, being based on functional changes in the way hormones are utilized by the patient's immune system, and not just by blood or saliva testing alone. Because of this, Dr. Amadi prefers to reassess hormones at least monthly or quarterly, in order to ensure that a person's current bio-identical hormone prescription matches their physiologic needs as closely as possible.

I understand that if I am being reimbursed by insurance for some or all of the cost of my visits to Dr. Amadi, that the insurance company may request copies of my office visits and that the insurance companies may or may not understand Dr. Amadi's notes re: the electromagnetic treatments and assessments that I have received and that they may not regard Dr. Amadi's treatments as being "medically necessary" (to manage a disease). Dr. Amadi makes no representations as to whether or not insurance companies will understand, approve of or reimburse for her care.

Dr. Amadi makes no guarantees regarding whether her treatments will cure or diagnose or prevent any diseases, just that she will do her best to provide the best care she knows how to give, in the time that the Member has allotted to her for treatment. Dr. Amadi will make recommendations concerning how often she thinks the Member should return for treatment but she is not responsible for the results or lack thereof that come about if the Member does not follow these recommendations.

Dr. Amadi's treatments and medical records are for the express purpose of improving the Member's health. Dr. Amadi does not participate in any legal proceedings regarding the Member's health, i.e. depositions or court appearances. If the Member is wanting to file disability or other medical/legal claims, they need to initiate and follow-up care with a doctor who is experienced in, and agrees to participate in, these kinds of legal proceedings.

I, _________________________________, have chosen to be a patient of Dr. Amadi's, and to be assessed and treated in the holistic way that has been outlined above.

___________________________________

Member's Signature - (PLEASE NOTE: YOU WILL SIGN THIS FORM WHEN YOU COME IN FOR YOUR APPOINTMENT)