DR. NALINI YELAMANCHI

Last Name

First Name

Middle Initial

Date of Birth

Age

Marital Status

Sex

Contact Information

Social Security Number

Local Address

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State

Zip Code

Home Phone

Cell Phone

Out of State Address (if any)

Address

City

State

Zip Code

Emergency Contact

Name (Last, First, MI)

Phone Number

Relationship to Patient

Address

City

State

Zip Code

Spouse Information

Name (Last, First, MI)

Date of Birth

Social Security Number

Mailing Address (if different)

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State

Zip Code

Home Phone

Cell Phone

PRIMARY INSURANCE INFORMATION

NAME OF INSURANCE COMPANY

PHONE

ID/SUBSCRIBER NUMBER

GROUP NUMBER

SUBSCRIBER NAME

RELATIONSHIP TO PATIENT

SUBSCRIBER SSN

SUBSCRIBER DOB

SUBSCRIBER GENDER

CONSENT TO USE AI SCRIBE DURING ENCOUNTERS

We are committed to providing you with the best care possible. To enhance our services, we are using a new technology called "AI scribe" during your visit.

What is AI Scribe? AI Scribe is an artificial intelligence (AI) tool that assists us during patient encounters by generating clinical notes based on our conversations.

How it works: This tool allows us to focus more on you, the patient, and less on computer documentation. The AI tool does not interact with you directly. It merely listens to the conversation and creates a summary. This note is then reviewed and approved by your practitioner.

Privacy and Security: Your privacy is our utmost priority. The AI tool adheres strictly to Health Insurance Portability and Accountability Act (HIPAA) compliance guidelines to ensure your data is secured and protected. Only the healthcare professionals involved in your care will have access to these notes.

Voluntary Participation: Your participation is completely voluntary. If you agree to use the AI scribe during your consultations, please sign and date the form below. If you have any questions, please feel free to discuss them with us.

I consent to the use of AI Scribe during my medical encounters

Patient Signature

Parent/Guardian Signature (if under 18)

Date

HIPAA 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.

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

Treatment: We may use your health information to provide you with our professional services. We have established "minimum necessary or need to know" standards that limit various staff members' access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.

Disclosure: We may disclose and/or share your health care information with other healthcare professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.

Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access: Upon written request, you have the right to inspect or get copies of your health information, and that of an individual for whom you are a legal guardian.

Amendment: You have the right to request your provider to amend your health care information, if you feel it is inaccurate or incomplete.

Non-Routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your healthcare information.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information.

QUESTIONS AND COMPLAINTS

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us, in writing.

HOW TO CONTACT US

Privacy Officer: Ram Moorthy, PO Box 173126, Tampa FL 33672, Phone: 800-521-9066, Email: compliance@betterhealthgroup.com

I acknowledge that I have reviewed the HIPAA Notice of Privacy Practices

CONSENT TO DISCUSS MEDICAL CONDITION OR RELEASE RECORDS

I, the below named patient, do hereby authorize Better Health Group, including but not limited to National Family Medical Associates, LLC, Florida Medical Associates, LLC, Physician Partners LLC, VIPcare, SaludVIP, Votion, etc., to discuss my medical condition with, or release my medical records to the below named person(s):

Name of Person

Relationship

Phone/Email

Initial Here

CONSENT TO OBTAIN AND USE PRESCRIPTION AND OTHER MEDICAL HISTORY

I, the below named patient, do hereby authorize Better Health Group, including but not limited to National Family Medical Associates, LLC, Florida Medical Associates, LLC, Physician Partners LLC, VIPcare, SaludVIP, Votion, etc., to obtain, access, and use my prescription medication history and other medical history from other healthcare providers such as hospitals, consultants, labs, or pharmacies, or third-parties such as payors and/or health information exchanges for treatment or other medical decision making purposes.

Initial Here

CONSENT TO PARTICIPATE IN HEALTH INFORMATION EXCHANGE

I, the below named patient, do hereby authorize Better Health Group, including but not limited to National Family Medical Associates, LLC, Florida Medical Associates, LLC, Physician Partners LLC, VIPcare, SaludVIP, Votion, etc., to participate in Health Information Exchange ("HIE") as required by Law and/or for betterment of healthcare operations. I further authorize the above parties to submit my PHI to such HIEs as allowed by law and/or required for healthcare operations and protected by HIPAA.

Initial Here

CONSENT TO TREAT

I consent to and authorize Better Health Group, including but not limited to National Family Medical Associates, LLC, Florida Medical Associates, LLC, Physician Partners LLC, VIPcare, SaludVIP, Votion, etc., to perform healthcare examinations, treatment, testing (including diagnostic imaging and/or laboratory), transfers, and referrals as deemed necessary in their professional judgment.

Signature of Patient or Legally Authorized Representative

Date

PHARMACY INFORMATION

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Forms

Contact Information

Out of State Address (if any)

Emergency Contact

Spouse Information

Health/History Questionnaire

Dates of Tests

Past Surgical History

Family History

Father

Mother

Siblings

Children

Social History

Review of Symptoms

General

Skin & ENT

Pulmonary & Cardiology

Gastrointestinal & Urinary

Gynecological & Hematology

Neurology & Rheumatology

MEDICATIONS LIST

PRIMARY INSURANCE INFORMATION

CONSENT TO USE AI SCRIBE DURING ENCOUNTERS

HIPAA NOTICE OF PRIVACY PRACTICES

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

YOUR PRIVACY RIGHTS AS OUR PATIENT

QUESTIONS AND COMPLAINTS

HOW TO CONTACT US

CONSENT TO DISCUSS MEDICAL CONDITION OR RELEASE RECORDS

CONSENT TO OBTAIN AND USE PRESCRIPTION AND OTHER MEDICAL HISTORY

CONSENT TO PARTICIPATE IN HEALTH INFORMATION EXCHANGE

CONSENT TO TREAT

PHARMACY INFORMATION

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