Notice of Privacy Practices

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1 Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. The law protects the privacy of the health information we create and obtain in our medical evaluation. For example, your protected health information (PHI) includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected health information for purposes of evaluation, treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes. Examples of use and disclosures of PHI for treatment and payment For evaluation: Information obtained by a physician or other member of our health care team will be recorded in your medical record and used to provide an evaluation of your current medical condition. We may also provide information to others providing your care or to those who are authorized to have access through the claims process. This will help them stay informed about your care. For payment: Information about services performed will be provided to others by OMAC for billing purposes. This information may consist of your IME, test results or services performed. Our responsibilities We are required to: Keep your PHI private Give you this notice Follow the terms of this notice We have the right to change our practices regarding the PHI we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick one up. To ask for help or voice a concern If you have questions, want more information, or want to report a problem about the handling of your PHI, you may contact: OMAC 401 Second Avenue South, Suite 110 Seattle, WA You may also file a complaint with the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. Revised 11/05

2 Personal Information Examinee Information (Exam Form) Name: Gender: M / F of Birth: Age: Address: Inc. City & State Phone: ( ) Ht: Wt: Dom. Hand: Lt. Rt. # of Dependents: Marital Status: Military Service:Y N Branch: Highest Level of Education: Hobbies: Exercise (type & Frequency): Tobacco (Packs/ day): Alcohol (Drinks/week): Illicit Drugs: Please write in N/A if not applicable Please write in N/A if not applicable Please write in N/A if not applicable Current Medications: Prior Surgeries: Allergies: Employment Information Employer at time of injury: Claim #: Are you currently working? Y N If not why? List any work related benefits you are receiving (Short term disability, long term disability, employer sponsored Medical,etc.) Family History Please list any chronic medical conditions and/or illnesses, which run in your family (diabetes, high blood pressure, heart disease, cancer, etc.). Mother: Father: I UNDERSTAND THAT I AM BEING SEEN FOR AN INDEPENDENT MEDICAL EVALUATION BY THE DOCTOR(S) AND NO TREATING PHYSICIAN/PATIENT RELATIONSHIP IS ESTABLISHED. I UNDERSTAND THAT THE INFORMATION I DISCUSS WILL BE INCLUDED IN A REPORT THAT IS PREPARED FOR THE REQUESTING CLIENT. I ALSO UNDERSTAND THE EXAMINING PHYSICIAN IS PERMITTED TO PROVIDE THIS REPORT TO THE REQUESTING PARTY. I UNDERSTAND THE DOCTOR WILL NOT DISCUSS THE RESULTS OF MY EVALUATION WITH ME AND WILL NOT RENDER ANY MEDICAL ADVICE OR TREATMENT TO ME. I CONSENT TO THIS REPORT BEING SENT TO THIS CLIENT AND TO PARTICIPATING IN THE ASSESSMENT. I AGREE TO ADVISE THE PHYSICIAN IMMEDIATELY IF I EXPERIENCE ANY DIFFICULTIES DURING THE EXAMINATION. I UNDERSTAND I AM ENTITLED TO A COPY OF THIS REPORT AND MUST OBTAIN IT THROUGH THE REQUESTING CLIENT. THIS EXAMINATION WILL BE KEPT CONFIDENTIAL IN ACCORDANCE WITH ALL APPLICABLE LAWS. TO BE SIGNED AT THE TIME OF THE EXAM SIGNED: DATE: WITNESS: DATE:

3 Please Check All That Apply: HEENT: Glasses or contacts Foreign body in eyes Weak eyes Eye surgery Recurrent ear infections Sinus or nasal passage problems Double vision Tear duct problems Hearing problems Cardiovascular: Irregular heart beat Chest pain Night sweats Coronary artery disease Heart murmur High blood pressure Varicose veins Pulmonary: Asthma Chronic cough Unusual shortness of breath Gastrointestinal: Swallowing problems Appetite problems Digestion problems Ulcers Heartburn Nausea Gall bladder problems Jaundice Vomiting blood Rectal bleeding Genitourinary: Kidney disease Bowel or bladder problems STD Urinating difficulty Bladder infection Pelvic inflammatory disease Prostate problems 2/18/2011 Examinee Medical History (Review of Systems) Hematologic: Anemia/leukemia Lymphoma Abnormal cell count Abnormal platelet count Blood thinner use Dermatologic: MRSA Eczema Psoriasis Fungal infection Unusual moles Skin cancer Severe acne Tattoos Endocrinologic: Thyroid problems Pituitary gland problems Adrenal gland problems Diabetes Neuropsychiatric: Convulsions Anger control problems Mental illness Sleep problems Mood swings Anxiety Depression Musculoskeletal: Systemic arthritis Neck pain Back pain Joint pain Fibromyalgia List any fractures or broken bones: Signature: :

4 Pain Diagram Using the diagrams below, circle and label the areas where you feel any of the following sensations: 1. Numbness 2. Pins and Needles 3. Burning Pain 4. Stabbing Pain 5. Aching Pain If the sensation is spreading to other areas, use arrows to indicate where and in which direction. Please fill this out as carefully as possible, as it helps the physician to better understand where and how you are hurting. Front Back Right Left Left Right Please briefly describe your injury; Signature 401 Second Avenue South Suite 110 Seattle WA Telephone: Toll Free: Fax:

5 Medical Records Release/Notification of Privacy Rights I understand that by refusing to complete this form Objective Medical Assessment Corporation may be unable to produce a complete Independent Medical Exam report regarding my claim. Examinee Name: (Print) Limitations on the information subject to this Release Form are as follows: Limited to Area of Injury: (please list injured body part(s) Release my protected health information to the following entity: Objective Medical Assessments Corporation 401 Second Avenue South, Suite 110 Seattle, WA The reasons for this release of information are as follows (check one): Worker s compensation medical examination Auto accident/casualty medical examination Crime victim/personal injury medical examination By my signature below I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the entity listed above. Examinee signature (his or her parent and or legal guardian) Acknowledgment of privacy practices: In conjunction with the claims manager and/or caretaker assigned to your case, we keep a record of the health care services we provide you. By contacting your claims manager or his or her medical or legal representative, you may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to persons or parties other than your claims manager and/or his or her medical or legal representative, unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting your claims manager and/or his or her medical or legal representative. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access that information. By my signature below I acknowledge receipt of the Notice of Privacy Practices. Examinee signature (his or her parent and or legal guardian)

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