Patient General Information
- Friendly & professional administrative staff
- The highest quality of comprehensive care
- State-of-the-art technology and equipment
For efficient processing, please provide the following electronic records on CD or USB flash drive before your first consultation with Dr. Sampson. These items are not required but are very helpful to the diagnosis process.
For your convenience, you may complete the printable forms below and either fax them to our office ahead of time or bring them with you to your appointment. We recommend, in order to safeguard your personal information, that you do not e-mail these forms to us. If you have any questions regarding this process, please call our office.
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With this form you will provide the following information:
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With this form you will mark the areas on your body where you feel the sensations of:
Notice of Privacy Practices for Protected Health Information
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.
Our office is permitted by federal privacy laws to make uses and disclosures of your health information for the purposes of treatment, payment, and healthcare operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples of uses of your health information for treatment purposes are:
A nurse or medical assistant obtains treatment information about you and records it in a health record; During the course of your treatment, the physician determines he will need to consult with another specialist in the area. He will share the information with such specialist and obtain his/her input.
Example of use of your health information for payment purposes:
We submit requests for payment to your health insurance company. The health insurance company or business associate helping us obtain payment may request information from us regarding your medical care given. We will provide information to them about you and the care given.
Example of use of your information for Healthcare operations:
We may obtain services from business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such business associates as necessary to obtain these services.
Our office is required to:
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice”, or by visiting our office and picking up a copy.
The health and billing records we maintain are the physical property of Dr. Sampson.
You have the following rights with respect to your Protected Health Information:
If you want to exercise any of the above rights, please contact the office manager at (415) 776-7878 ext. 152, or in person at 2299 Post Street, Suite 107 during normal business hours. We will provide you with the assistance on the steps to take to exercise your rights.
To Request Information or To File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the office manager at (415) 776-7878. Additionally, if you believe your privacy rights have been viola
ted, you may file a written complaint at our office by delivering the written complaint to the office manager. You may also file a complaint by submitting it in writing the Secretary of Health and Human Services.
We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from this office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
How We May Use and Disclose Medical Information about You
The following categories describe different ways we may use and disclose your health information. Not every use or disclosure in a category may be listed, but all circumstances in which we may use and disclose your information as provided by law will fall within one of these categories.
For Treatment: We may use medical information about you to provide you with medical treatment and services. We may disclose your healthcare information to doctors, nurses, technicians, medical students, or other facility personnel who are involved in your care at Dr. Sampson’s practice.
For Payment: We may use and disclose your healthcare information so the treatment and services you receive may be billed, and payment made either by you, an insurance company, or a third party. This may also include the disclosure of medical information to obtain prior authorization for treatment and procedures from your insurance company.
For Healthcare Operations: We may use and disclose your healthcare information for standard office operations. These uses and disclosures may be necessary for normal operations, and to make sure all of our patients receive quality care. Examples include:
Patient Contact: We may contact you to provide you with appointment reminders, information about treatment alternatives, or with information about other health-related benefits and services that may be of interest to you.
Notification – Opportunity to Agree or Object:
If you are present and able, and do not object, or if you are not present, able, or in an emergency, using our professional judgment, we may:
We may use and disclose your protected health information to assist in disaster relief efforts.
Notification—Opportunity to Agree or Object—Not Required
Public Health Activities:
Controlling Disease: As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Child Abuse & Neglect: We may disclose protected health information to public authorities as allowed by law to report child abuse or neglect.
Food and Drug Administration (FDA): We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Employers, Case Managers, Attorneys: We may disclose your protected health information for the treatment of work related injuries to employers, case managers, claim adjusters, and related attorneys to the extent necessary to comply with laws in relation to Workers Compensation.
Victims of Abuse, Neglect, or Domestic Violence: We can disclose protected health information to governmental authorities to the extent the disclosure is authorized by statute or regulation and in the exercise of professional judgment the doctor believes the disclosure is necessary to prevent serious harm to the individual or other potential victim.
Oversight Agencies: Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities to include audits, civil, administrative or criminal investigations, inspections, licensures or disciplinary actions, and for similar reasons related to the administration of healthcare.
Judicial/Administrative Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceedings as allowed or required by law, or as directed by a proper court order or administrative tribunal, provided that only the protected health information released is expressly authorized by such order, or in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your protected health information for law enforcement purposes as required by law, such as when required by court order, including laws that require reporting of certain types of wounds or other physical injury.
Coroners, Medical Examiners and Funeral Directors: We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs, eyes, or tissue for the purpose of donation and transplant.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Threat to Health and Safety: To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.
For Specialized Governmental Functions: We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Correctional Institutions: If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.
Other Uses and Disclosures: Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization which you may revoke except to the extent information or action has already been taken.
Effective Date of this Notice 2010