By signing this form I give my general consent to the care and treatment as deemed appropriate by Raymond Zakhari, NP and his designees. I understand that not signing this may be harmful to my condition as Raymond Zakhari, NP may not be able to render care to me in a timely manner. Care may be rendered to me in my home, office, hotel or any other place that is mutually agreeable to both parties.
I understand that the care provided in this practice is rendered by a Nurse Practitioner. If my care requires more advanced level care the Nurse Practitioner will advise me to see a specialty physician. I understand that It is my responsibility to follow through on referrals and recommendations for care and that not following the recommendations may be to the determent of my personal health and well being.
I grant Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC to release personal information to the appropriate authorities as deemed appropriate under the law e.g. (if another individual is likely to be harmed by an action as a result of my action, if I express homicidal or suicidal thoughts or communicate in anyway an intent to follow through, reveal child abuse etc.), and to other health care providers that have been or will be involved in my care e.g. my primary care provider, specialist or comparable service provider. I also understand that care may denied if it is discovered by any means that I am obtaining controlled substances from other health care providers and failing to disclose this information. This consent shall remain in effect until I revoke it in writing and my revocation is subject to the laws of the state of New York.
An electronic version or copy of this form shall be as effective as the original. By signing electronically this is equal to signing with pen.
Receipt of Notice of Privacy Practices: I acknowledge that a copy of the Notice of Privacy Practices of Metro Medical Direct is available to me upon request and is also available: MetroMedicalDirect.com.
I understand that a copy or electronic version of this agreement may be used with the same effectiveness as the original. I hereby give my consent for Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC (Metro Medical Direct) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations. The Notice of Privacy Practices provided describes such uses and disclosures more completely and is continually available on web site MetroMedicalDirect.com
I have the right to review the Notice of Privacy Practices prior to signing this consent. The practice reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Raymond Zakhari, NP or by going to www.MetroMedicalDirect.com
With this consent the practice may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, the practice may mail to my home or other alternative location any items that assist the practice in carrying out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS, such as appointment reminder cards and patient statements." With this consent, the practice may e-mail to my home or other alternative location any items that assist the practice in carrying out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS, such as appointment reminder cards and patient statements. I have the right to request that PRACTICE restrict how it uses or discloses my PHI to carry out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC (Metro Medical Direct [the practice]) to use and disclose my PHI to carry out treatment, payment, and health care operations.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC may decline to provide treatment to me without any liability.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical and dental records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse Protected Health Information (PHI).
This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Your Protected Health Information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the practice, and any other use required by law.
Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the health care professional has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, and conducting or arranging for other business activities. We may use or disclose, as needed, your protected health information to support the business activities of this practice. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may call your home and leave a message (either on an answering machine or with the person answering the phone) to remind you of an upcoming appointment, the need to schedule a new appointment or to call our office. We may also mail a postcard reminder to your home address. If you would prefer that we call or contact you at another telephone number or location, please let us know.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of HIPAA.
Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
The Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in you care or for notification purposes described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice alternatively (i.e. electronically).
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this Notice and will inform you of any changes. You then have the right to object or withdraw as provided in this Notice.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint at our office and main telephone number. We will not retaliate against you for filing a complaint.
Metro Medical Direct
Raymond Zakhari, NP
Mobile Phone: (917) 484-2709
Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.