˛ˆ ˚ ˇ jxÄvÉÅx

jxÄvÉÅx jxÄvÉÅx jxÄvÉÅx jxÄvÉÅx It is with great pleasure that we welcome you to PMA Medical Specialists. Our Physicians

Network is comprised of Primary and Specialty Care physicians and healthcare providers that understand the

importance of providing pa ents with Con nuous Coordinated Healthcare. We are commi#ed to mee ng the

healthcare needs of our pa ents by offering a wide-range of medical special es and pa ent services to help you stay

healthy. To serve you be#er, most PMA Physicians and Providers are on-staff at Phoenixville Hospital and Po#stown

Memorial Medical Center.

For your convenience, we have enclosed a health ques onnaire and addi onal forms to be

completed prior to your first appointment. We have also included helpful informa on about our

prac ce and ways to make your healthcare journey less daun ng. If you have any ques ons while filling out the

forms, please feel free to contact the office where you will be seen. Please bring all of your completed forms to your

first appointment.

We believe in giving back to the communi es which we serve, and are ac vely involved in area groups and programs

that evoke posi ve change throughout our region.

PMA Medical Specialists has office loca ons throughout Montgomery and Chester coun es, including Audubon,

Collegeville, Limerick, Paoli, Phoenixville, Po#stown and Schwenksville, PA. Visit pmadoctor.com for

complete list of special es, loca ons and hours, insurances that we accept, and frequently

asked ques ons.

Our Office Managers are here to help you with whatever issue you may have, please feel free to speak with them regarding any of

your concerns. We look forward to mee ng you and becoming your partner in healthcare!

AUDUBON | COLLEGEVILLE | LIMERICK | PAOLI | PHOENIXVILLE | POTTSTOWN | SCHWENKSVILLE

PrimaryCare| AllergyandClinicalImmunology| Cardiology| CriticalCareMedicine| DiabetesEducation

Electrophysiology| Endocrinology| Gastroenterology| NutritionalCounseling| PainManagement

Pulmonology| Rheumatology| SleepMedicine

Specializing in �� care for long-term health and wellbeing.

Allergy and Immunology Nutri�onal Counseling

Cardiology Pain Management

Cri�cal Care Medicine Primary Care —

Diabetes Educa�on Internal, Family & Geriatric Medicine

Electrophysiology Pulmonology

Endocrinology Rheumatology

Gastroenterology Sleep Medicine

Enjoy the advantage and convenience of having a PMA primary care physician or specialist close to home:


PATIENT INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE (if Applicable)

NAME (Last, First Middle) MRN SSN# BIRTHDATE LANGUAGE SEX

LOCAL ADDRESS SECONDARY/BILLING ADDRESS (if Applicable) ETHNICITY

CITY, STATE ZIP HOME PHONE CITY, STATE ZIP SECONDARY HOME PHONE RACE

PRIMARY CARE PHYSICIAN REFERRING PHYSICIAN CONTACT NAME CONTACT HOME PHONE

PRIMARY EMPLOYER SECONDARY EMPLOYER (if Applicable)

ADDRESS ADDRESS

CITY, STATE ZIP CITY, STATE ZIP

WORK PHONE WORK PHONE

NAME (Last, First Middle) SSN# BIRTHDATE LANGUAGE SEX

LOCAL ADDRESS SECONDARY/BILLING ADDRESS (if Applicable)

CITY, STATE ZIP CITY, STATE ZIP

HOME PHONE SECONDARY HOME PHONE

RELATIONSHIP TO PATIENT

NAME OF INSURANCE COMPANY POLICY#

NAME OF INSURED GROUP#

ADDRESS OF INSURANCE COMPANY COPAY AMT

CITY, STATE ZIP DEDUCTIBLE

RELATIONSHIP TO PATIENT EFFECTIVE DATE EXPIRATION DATE

NAME OF INSURANCE COMPANY POLICY#

NAME OF INSURED SSN# BIRTHDATE GROUP#

ADDRESS OF INSURANCE COMPANY COPAY AMT

CITY, STATE ZIP DEDUCTIBLE

RELATIONSHIP TO PATIENT EFFECTIVE DATE EXPIRATION DATE

I request that payment of authorized Medicare benefits be made either to me or on my behalf to PMA Medical Specialists, LLC for any services furnished to me by PMA Medical Specialists, LLC. I authorize any holder of medical information about me to release to the Centers for Medicare Services and its agents any information needed to determine these benefits or the benefits payable for related services.

SIGNATURE OF PATIENT/GUARDIAN DATE

RESPONSIBLE PARTY INFORMATION (if Different than above)

$

$

$

$

PMA Medical Specialists LLCPO Box 525

Phoenixville, PA 19460-0525

USA

(610) 917-9281

PATIENT HEALTH HISTORY

Pa�ent Name ____________________________________________________________________________________________

DOB _____________________________________________ Date_________________________________________________

Referring Physician ________________________________________________________________________________________

Primary Care Physician _____________________________________________________________________________________

(if other than referring Physician)

Preferred Pharmacy _________________________________ Phone # _____________________________________________

Emergency Contact __________________________________ Phone # _____________________________________________

Do you have an advanced direc�ve? yes no (If so, please bring a copy to your scheduled appointment)

MEDICATIONS: Please list ALL MEDICATIONS (including over the counter) that you are currently taking and the reason

you are taking them:

PAST MEDICAL HISTORY: Please circle all that apply:

Heart Disease Asthma Diabetes COPD Hepa��s Stroke

Bleeding Disorder High Blood Pressure Drug Dependency Other: __________________________________

______________________________________________________________________________________________________

SURGICAL HISTORY:

DRUG DOSE TIMES A DAY REASON

SURGERY YEAR COMMENTS





PLEASE LIST ALL NON-PMA MEDICAL SPECIALISTS PHYSICIANS:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

CURRENT EMPLOYER/OCCUPATION:

___________________________________________________________________________________________________________

SOCIAL HISTORY:

Do you drink alcohol? � Yes � No � Occasionally � Weekly

Have you ever smoked tobacco? � Yes � No If so, how long? ____________________________

Have you ever used non-smoking tobacco? � Yes � No If so, what type? � Chewing � Smokeless � Snuff

Have you been environmentally exposed to second hand smoke? � Yes � No

Have you been exposed to second hand smoke? � Yes � No

Marital Status � Married � Single � Divorced � Widow

Student Status � Full-�me � Part-�me

SAFETY:

Do you have firearms in the home? � Yes � No

Do you have smoke detectors in the home? � Yes � No

Do you have radon in the home? � Yes � No If so, has it been treated? � Yes � No

Do you use seatbelts while in vehicles? � Yes � No

FAMILY HISTORY:



DISEASE

Heart Disease

FAMILY MEMBER COMMENTS

Asthma

Diabetes

COPD

Hepa��s

Stroke

Bleeding Disorder

High Blood Pressure


Other




ALLERGIES:

� None � Latex

� Penicillin (reac�on) ________________________________ � Erythromycin (reac�on) _____________________________

� Sulfa (reac�on) ____________________________________ � Codeine (reac�on) _________________________________

Please list any other allergies and the reac�on that you had:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Please request a copy of your current medical records and bring it with you to your 1st scheduled appointment. The federal

Health Informa�on Portability and Accountability Act (HIPAA) gives pa�ents the right to obtain a copy of their medical records

from any medical provider, with a few excep�ons. HIPAA also requires medical providers to provide copies of medical records

within 30 days of your request (this may vary by state). If it will take more than 30 days to meet your request, the medical provid-

er must give you a reason for the delay. Contact your provider to determine the best channel to make the request – we recom-

mend that you do it in wri�ng.

The above responses are accurate to the best of my knowledge.

Date _____________________________________________________________________________________________________

Pa�ent Signature

_________________________________________________________________________________________________________

(must be 18 years of age or parent/legal guardian)

Signature of Parent of Legal Guardian

_________________________________________________________________________________________________________

Medical Record Release Authorization

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

__________________________ ______________________________________________________**Subject to Fees (Date) (Signature of Patient/Parent/Guardian or Authorized Representative)

Patient Name______________________________Maiden Name________________SS#___________ Date of Birth_______________Home Phone____________________Cell/Work___________________ Address_________________________________________City/State/Zip________________________ Email Address: ______________________________________________________________________

I have read the information provided on this release form and do hereby acknowledge that I am

familiar with and fully understand the terms and conditions of this authorization.

*PLEASE READ Fee Information: PMA Medical Specialists contracts with DataFile Technologies to copy and provide all medical records requested from our office. DataFile Technologies reserves the right to charge the medical record state fee structure as set forth in the state statute. Copy charges plus postage will be invoiced to you from DataFile Technologies, LLC with all of the necessary directions to receive your records. By signing this authorization, you are agreeing to pay DataFile Technologies for your records. In the case of continuity of care or personal copy to patient, DataFile Technologies may transfer a minimal portion of your records as a courtesy.

DataFile Technologies: 816-437-9134 2017 Authorization Form

This authorization will expire one year from the above date unless I specify an expiration date: _________________________ (Expiration date of authorization)

A) I hereby authorize records FROM: Name________________________________________

Address______________________________________

City/State/Zip__________________________________

Phone#__________________Fax#___________________

Date Range_____________________to___________________

Physician Office Notes Cardiology/EKG Reports

Immunizations Lab/Path Reports

Operative/Procedure Reports Radiology/XRay/MRI Reports

B) To be released TO: Name____________________________________________________________

Address__________________________________________________________

City/State/Zip______________________________________________________

Phone#______________________FAX#________________________________

C) For the purpose of: _____ Litigation _____ Disability _____ Insurance _____ Work Comp _____ Self/Personal Copy _____ Other _____ Continuity of Care _____ Transfer of Care (Permanently Leaving)

PAYMENT POLICY

Thank you for choosing PMA Medical Specialists as your medical provider. We are commi�ed to providing you with quality and

affordable healthcare; our fees are representa#ve of the usual and customary charges for our area. Please review our payment

policy below and sign in the space provided. A copy will be provided to you upon request. KNOWING YOUR INSURANCE BENEFITS

IS YOUR RESPONSIBILITY. PLEASE CONTACT YOUR INSURANCE COMPANY WITH ANY QUESTIONS YOU MAY HAVE REGARDING

YOUR COVERAGE.

1. Insurance/Proof of Insurance All pa#ents must complete a pa#ent informa#on form prior to any services being provided.

We par#cipate in most insurance plans (for a complete list visit www.pmadoctor.com/faq.aspx), including Medicare. WE ASK THAT

YOU PRESENT YOUR CURRENT INSURANCE CARD AT EACH VISIT. If you are not insured by a plan with which we par#cipate,

payment in full is expected at each visit. If you are insured by a plan with which we par#cipate, payment may be required in full

un#l we can verify your coverage. If you fail to provide us with the correct insurance informa#on in a #mely manner, you may be

responsible for payment in full for the services provided to you.

2. Co-payments and deduc,bles. For commercial insurance plans, all co-payments and deduc#bles must be paid at the #me of

service. This arrangement is part of your contract with your insurance company.

3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not

considered reasonable or necessary by Medicare or other insurers. You may be required to complete an Advance Beneficiary

No#ce of Non Coverage to acknowledge receipt of these services and to accept the associated financial responsibility for these

services.

5. HMO Referrals. If required by your insurance, you must provide a valid referral at the #me of service. If a referral is not

available, you will be required to obtain one from your primary care physician at that #me, or reschedule your appointment.

Your insurance company does not permit us to bill you (even if you sign a waiver or Advance Beneficiary No�ce of Non Coverage)

for services we provide if a referral is required for the service and we do not obtain the referral at the �me of service.

6. Claims submission. We will submit your claims to your insurance company and are happy to assist you in any way we

reasonably can to ensure that your claims are paid. However, your insurance company may need you to provide them with certain

informa#on directly, and it is your responsibility to respond promptly to their request. Please be aware that if you fail to do so,

your insurance company may not pay the claim and we will be required to bill you for the full amount of the claim. Please

remember, your insurance benefit is a contract between you and your insurance company; PMA is not a party to that contract.

7. Coverage changes. If your insurance changes, please no#fy us before your next visit so we can make the appropriate changes

in your billing records to help you receive your maximum benefits.

8. Nonpayment. If your account is over 90 days past due, you will receive a le�er sta#ng that you have 30 days to pay your

account in full. You are encouraged to pay your balance in full. However, if you are unable to pay in full, PMA is willing to work

with you to establish a payment plan to assist in paying an open account balance. Please be aware that if a balance remains

unpaid, we may refer your account to a collec,on agency.

9. Missed appointments. If you miss appointments on regular basis, you may either be charged a $20.00 fee for those missed

appointments or you may discharged from the prac,ce. Please help us to serve you be=er by keeping your regularly scheduled

appointment or by contac,ng us within 24 hours of your scheduled appointment to re-schedule.

Thank you for understanding our payment policy and terms. Please let us know if you have any ques#ons or concerns.

I have read and understand the payment policy and agree to abide by its guidelines:

__________________________________________________________ ______________________

Signature of pa,ent or responsible party Date

__________________________________________________________ ______________________

Print Name Date of Birth

AUDUBON | COLLEGEVILLE | LIMERICK | PHOENIXVILLE | POTTSTOWN | SCHWENKSVILLE


Electrophysiology| Endocrinology| Gastroenterology| Pulmonology| Rheumatology| SleepMedicine

A U D U B O N | C O L L E G E V I L L E | L I M E R I C K | P A O L I | P H O E N I X V I L L E | P O T T S T O W N | S C H W E N K S V I L L E

At PMA Medical Specialists we believe that patients (their families and/or support persons) matter always, and as such, should be treated with respect and compassion. Your Rights and Responsibilities, outlined here, are part of the PMA Pledge to provide quality healthcare in a caring and compassionate manner.

PMA PATIENT RIGHTSinformation and communicationYou have the right to… • be educated regarding your rights • receive information regarding your health in a

method that you can understand • know the names of your caregivers and their role

in your healthcare • receive and review your medical record within a

reasonable time of request • be informed regarding your health status, recommended

tests, procedures, options, risks and benefits • have interpreting services, when possible,

if you do not speak English • a full breakdown regarding your bill if requested

and payment methods available

respect and privacyYou have the right to… • receive healthcare without unnecessary delay; without

regard to race, color, nationality, age, language, religion, mental or physical handicap, sex, sexual preference, gender identity or source of payment

• personal privacy and confidentiality of your health record – see HIPAA privacy practices

• keep your medical record and other healthcare information confidential, however we are required by law to share some types of information to your insurance provider in order for your care to be covered

quality healthcareYou have the right to… • quality care and high professional standards that

are continually maintained and reviewed • proper evaluation and treatment • receive care in a safe, clean and pleasant

environment • efficient time management of your healthcare • voice your concerns about the healthcare you are

receiving – please speak with your provider, practice manager, or any member of our healthcare team; you may also file a complaint with the PA Dept. of Health

decision makingYou have the right to… • be an active participant in your healthcare through

discussions with caregivers • be informed regarding anticipated outcomes of care,

treatments, and services • be informed regarding the benefits and risks

of your treatments • agree to or refuse treatments • make choices and to document those choices in

case you become too ill to speak for yourself - an Advance Directive

• designate someone to make healthcare decisions for you • seek a second opinion or alternate physician

PMA PATIENT RESPONSIBILITIESIt is your responsibility to… • be on-time for your scheduled appointment; we ask

that you arrive 15 minutes prior to your scheduled time • provide as much notice as possible when canceling an

appointment, so that we may offer that appointment to another patient

• provide photo ID, insurance information and co-pay at check-in

• provide us with complete and accurate information regarding your health status and history

• play an active role in your healthcare; ask questions when you are unclear regarding information and/or instructions

• let us know that you cannot follow or refuse treatments or instructions

• let us know of any changes in your health • provide us with a current list of medications that you

are taking, including over-the-counter medications and vitamins

• be considerate of other patients and employees of PMA Medical Specialists by following the rules of general etiquette

• pay your out-of-pocket-expense as dictated by your carrier plan

PMA Medical Specialists pledges to provide you with the highest quality healthcare possible. We will provide you and your caregivers the educational resources to help understand your prescribed care plans, the treatment options available, and our recommendations to help you stay healthy.

We are committed to being your partner in health.

PMA Patient Rights & Responsibilities

Comprehensive Care...In Your Neighborhood. pmadoctor.com

A U D U B O N | C O L L E G E V I L L E | L I M E R I C K | P A O L I | P H O E N I X V I L L E | P O T T S T O W N | S C H W E N K S V I L L E

Español (Spanish)PMA Medical Specialists, LLC cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

繁體中文 (Chinese)PMA Medical Specialists, LLC 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。

Tiếng Việt (Vietnamese)PMA Medical Specialists, LLC tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính.

한국어 (Korean)PMA Medical Specialists, LLC 은(는) 관련 연방 공민권법을 준수하며 인종, 피부색, 출신 국가, 연령, 장애 또는 성별을

이유로 차별하지 않습니다.

Tagalog (Tagalog – Filipino)Sumusunod ang PMA Medical Specialists, LLC sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian.

Русский (Russian)PMA Medical Specialists, LLC соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола.

(Arabic)

Kreyòl Ayisyen (French Creole)PMA Medical Specialists, LLC respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l’origine nationale, l’âge, le sexe ou un handicap.

Français (French) PMA Medical Specialists, LLC respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l’origine nationale, l’âge, le sexe ou un handicap.

Polski (Polish) PMA Medical Specialists, LLC postępuje zgodnie z obowiązującymi federalnymi prawami obywatelskimi i nie dopuszcza się dyskryminacji ze względu na rasę, kolor skóry, pochodzenie, wiek, niepełnosprawność bądź płeć.

Português (Portuguese)PMA Medical Specialists, LLC cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo.

Italiano (Italian)PMA Medical Specialists, LLC è conforme a tutte le leggi federali vigenti in materia di diritti civili e non pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso.

Deutsch (German)PMA Medical Specialists, LLC erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab.

日本語 (Japanese) PMA Medical Specialists, LLC は適用される連邦公民権法を遵守し、人種、肌の色、出身国、年齢、障害または性別に基づく差別をいたしません。

(Farsi)

PMA Medical Specialists complies with applicable Federal civil rights laws and does not discriminate on the basis of

race, color, national origin, age, disability, or sex.

Comprehensive Care...In Your Neighborhood.

pmadoctor.com

Deutsch (German)

PMA Medical Specialists, LLC erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt

jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht

ab.

(Japanese)

PMA Medical Specialists, LLC ��

��

�

(Farsi)

PMA Medical Specialists, LLC

.

Deutsch (German)

PMA Medical Specialists, LLC erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt

jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht

ab.

(Japanese)

PMA Medical Specialists, LLC ��

��

�

(Farsi)


.

(Arabic)


Kreyòl Ayisyen (French Creole)

PMA Medical Specialists, LLC respecte les lois fédérales en vigueur relatives aux droits civiques et ne

pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou

un handicap.

Français (French)



un handicap.

Polski (Polish)

PMA Medical Specialists, LLC post puje zgodnie z obowi zuj cymi federalnymi prawami

obywatelskimi i nie dopuszcza si dyskryminacji ze wzgl du na ras , kolor skóry, pochodzenie, wiek,

niepełnosprawno b d płe .

Português (Portuguese)

PMA Medical Specialists, LLC cumpre as leis de direitos civis federais aplicáveis e não exerce

discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo.

Italiano (Italian)

PMA Medical Specialists, LLC è conforme a tutte le leggi federali vigenti in materia di diritti civili e non

pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso.

(Arabic)


Kreyòl Ayisyen (French Creole)



un handicap.

Français (French)



un handicap.

Polski (Polish)

PMA Medical Specialists, LLC post puje zgodnie z obowi zuj cymi federalnymi prawami

obywatelskimi i nie dopuszcza si dyskryminacji ze wzgl du na ras , kolor skóry, pochodzenie, wiek,

niepełnosprawno b d płe .

Português (Portuguese)

PMA Medical Specialists, LLC cumpre as leis de direitos civis federais aplicáveis e não exerce

discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo.

Italiano (Italian)

PMA Medical Specialists, LLC è conforme a tutte le leggi federali vigenti in materia di diritti civili e non

pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso.

PMA Medical Specialists

NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUTYOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLYAND IF YOU HAVE ANY QUESTIONS ABOUT THE NOTICE, PLEASECONTACT ANY OF OUR DESIGNATED PRIVACY OFFICER(S):

Tim Rimmer (Practice Administration) – 610-933-8000Sarah Beauvilliers, RN (Phoenixville Offices, Audubon Office,

Collegeville Office) – (610) 933-8484Lisa Jack, LGPN (Limerick Office, Paoli Office, Schwenksville Office) – 610-495-2300

Desiree Hunsberger (Pottstown Offices, Suburbia Square Office) – 610-323-3100Brian Eckman, RN (PMA GI Center) – 484-938-4030

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations 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” (or “PHI” for short) is information about you, including demographic information, that may identify you and that relates to your past, present or future physicalor mental health or condition and related health care services including the payment for your health care.

We are required by law to maintain the privacy of your PHI and to provide you with this notice in-forming you of our legal duties and privacy practices with respect to your PHI. We are required to abideby the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. Thenew notice will be effective for all PHI that we maintain at that time. Upon your request, we will provideyou with any revised Notice of Privacy Practices at the time of your next appointment. We will also postthe revised notice in our office.

I. Uses and Disclosures of Protective Health Information

A. We may use and disclose your PHI for treatment, payment and health care operations. YourPHI may be used and disclosed by our health care providers and our office staff and others outside of ouroffice that are involved in your care and treatment for the purpose of providing health care services toyou. Your PHI may also be used and disclosed to pay your health care bills and to support the operationof our practice.

Following are examples of the types of uses and disclosures of your PHI that our office ispermitted to make. These examples are not meant to be exhaustive, but to describe the types of uses anddisclosures that may be made by our office.

1. We may use and disclose your PHI to provide health care treatment. We will use anddisclose your PHI to provide, coordinate, or manage your health care and any related services. This mayinclude communicating with other health care providers regarding your treatment and coordinating andmanaging your health care with others. For example, we may disclose your PHI when you need alaboratory study, a prescription, an x-ray or other health related services.

In addition, we may disclose your PHI from time-to-time to another physician or health careprovider such as a specialist who, at our request, becomes involved in your care by providing assistancewith your health care diagnosis or treatment to your physician.

EXAMPLE: When we schedule you for an MRI or x-ray, we will need to inform them of anyallergies you may have to the dye or other materials used in the procedure. If you are referred to anotherphysician for treatment, that physician may need to know of other health problems you may have ormedications that you are taking that might influence his treatment.

2. We may use and disclose PHI in order to obtain payment for services. Our office mayalso need to use and disclose your PHI to others in order to bill and collect payment for the treatmentand other services we provide to you. Before certain services are provided to you, we may need to sharesome of your PHI with your health plan. This will allow us to verify coverage or to obtain pre-approvalfor studies and other tests that we may need to order for your health plan to pay for them.We may also disclose identifiable health information to obtain payment from third partiessuch as insurance companies, employers, or family members that may be responsible for payment. Wemay also share portions of our PHI with our billing company or collection agency.EXAMPLE: Your insurance company or employer may request physician notes from a visitin order to approve payment for services.

3. We may use and disclose PHI for our health care operations. We may use or discloseyour PHI in order to support the business activities of our practice which we call “health careoperations”. These health care operations allow us to improve the quality of care we provide and reducehealth care costs.

Examples of the way we may use or disclose PHI about you for “health care operations”include, but are not limited to, reviewing the quality of services we provide to you, evaluating ourprofessional and business staff, having medical residents or students train in our office, and conductingor arranging for other business activities.

We may also: a) contact you to remind you of your next appointment with us or to provideyou with information about treatment alternatives or services that may be of interest to you, b) contactyou at work or home to notify you of test results, c) ask that you use a sign-in sheet at the registrationdesk when you come in for your appointment, d) confirm your demographic and insurance informationat the reception desk, e) assist you in scheduling medical services or obtaining necessaryreferrals/authorizations at the reception desk, and f) call you by name in the waiting room when yourhealth care provider is ready to see you. We also utilize a telephone answering service after office hours.We may also share your PHI with third party “business associates” that perform certainactivities for us or provide a service to us. These include our billing company, a management company ora transcriptionist who types our letters and notes. Whenever an arrangement between our office and abusiness associate involves the use or disclosure of your PHI, we will have a written contract thatcontains terms that will protect the privacy of your protected health information.

We will disclose identifiable health information only to the extent reasonably necessary toperform the above-mentioned activities of our practice. In some instances, we may need to use ordisclose all of the information, while other times, we may need to use or disclose only certaininformation.

B. You may agree or object to certain uses and disclosures we may make. If you agree, we maydisclose your PHI in the following instances. You may object to the use or disclosure of all or part ofyour PHI. If the opportunity to object to uses and disclosures cannot practically be provided because ofyour incapacity or in an emergency treatment circumstance, your health care provider may, usingprofessional judgment, determine whether the disclosure is in your best interest. In this case, only thePHI that is relevant to your health care will be disclosed.

1. We may disclose PHI to others involved in your health care. Unless you object, we maydisclose to a member of your family, a relative, a close friend or any other person you identify, your PHIthat directly relates to that person’s involvement in your health care. If you are unable to agree or objectto such a disclosure, we may disclose such information as necessary if we determine that it is in yourbest interest based on our professional judgment. We may use or disclose PHI to notify or assist innotifying a family member, personal representative, or any other person that is responsible for your care,of your location, general condition or death.

2. We may disclose PHI for disaster relief purposes. We may use or disclose your PHI to apublic or private agency authorized by law or charter to assist in disaster relief efforts such as theAmerican Red Cross.C. We may use or disclose your PHI in other situations without your authorization.

1. Required by Law. We may use or disclose your PHI to the extent that the use ordisclosure is required by law. The use or disclosure will be made in compliance with the law and will belimited to the relevant requirements of the law.

2. Public Health. We may disclose your PHI for public health activities and purposes to apublic health authority that is authorized by Pennsylvania law to collect or receive the information. Thedisclosure will be made for the purpose of controlling disease, injury or disability. For example, we arerequired under Pennsylvania law to report the presence of certain bacteria in laboratory tests, or theresults of a positive Lyme test.

If we are examining or treating you at the request of your employer, we are required todisclose your PHI that consists of findings we obtained during this examination/treatment to youremployer.

We may also disclose your PHI to an individual associated with the FDA in the event ofa drug recall or to report a side effect or adverse event.

We may disclose your PHI, if authorized by law, to a person who may have beenexposed to a communicable disease or may otherwise be at risk of contracting or spreading the diseaseor condition.

3. Health Oversight. We may disclose PHI to a health oversight agency for activitiesauthorized by law, such as audits, civil, administrative or criminal investigations, inspections, andlicensing activities.

4. Abuse or Neglect. Pennsylvania law requires that we report cases of child abuse toa government authority, if we have reasonable cause to suspect that a child is the victim of abuse.In addition, we may disclose your PHI if we believe that you (as an adult) are a victim of abuse,neglect or domestic violence to the governmental entity or agency authorized to receive suchinformation. In this case, the disclosure will be made consistent with the requirements of applicablefederal and Pennsylvania laws.

5. Judicial and Administrative Proceedings. We may disclose your PHI in response to acourt order or subpoena. (Note: In general, our office will request/require your written authorizationprior to disclosing your PHI in response to a subpoena.) All disclosures will be made consistent with therequirements of applicable federal and Pennsylvania law.

6. Law Enforcement. We may also disclose PHI so long as applicable legal requirementsare met, for law enforcement purposes. These law enforcement purposes include (1) legal processes andas otherwise required by law such as the reporting of certain types of injuries, (2) limited informationrequests for identification and location purposes, (3) if you are or may be a victim of a crime, (4)suspicion that your death has occurred as a result of criminal conduct, (5) in the event that a crimeoccurs on the premises of our practice, and (6) if we provide medical care in response to a medicalemergency and it is likely that a crime has occurred.

7. Coroners and Funeral Directors. We may disclose PHI to a coroner or medical examinerfor identification purposes to determine cause of death or for the coroner or medical examiner to performother duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law, inorder to permit the funeral director to carry out his duties.

8. Organ Donation. PHI may be used and disclosed to organ procurement organizationsfor cadaveric organ, eye or tissue donation purposes.

9. Research. If we disclose your PHI for research, we will comply with federal andPennsylvania law regarding such disclosures. An authorization will also be obtained from you.

10. To Avert Serious Threat. We may disclose your PHI if we believe in good faith that theuse or disclosure is necessary to prevent or reduce a serious and imminent threat to the health and safetyof another person or the public. Under these circumstances, we will only disclose health information tosomeone who is able to help prevent or lessen the threat.

11. For Government Functions. Consistent with applicable federal laws, we may discloseyour PHI if you are a member of the Armed Forces (1) for activities deemed necessary by appropriatemilitary command authorities; (2) for the purpose of a determination by the Department of VeteranAffairs of your eligibility for benefits; or (3) to a foreign military authority if you are a member of thatforeign military services. We may also disclose your PHI to authorized federal officials for conductingnational security and intelligence activities, including for the provision of protective services to thePresident or other individuals. Also, we may disclose to a correctional institution or law enforcementofficials having legal custody of the inmate.

12. Workers’ Compensation. Your PHI may be disclosed by us as authorized to comply withworkers’ compensation laws and other similar government programs that provide public benefits.

D. We are required to disclose your PHI upon request to the Secretary of HHS. We are requiredto disclose your PHI to the Secretary of Health and Human Services to investigate or determine ourcompliance with the Privacy Regulations.

E. All other disclosures require your written authorization. Other uses and disclosures of yourPHI will be made only with your written authorization, unless otherwise permitted or required by law asdescribed below. You may revoke this authorization, at any time, in writing, except to the extent that wehave taken an action in reliance on the use or disclosure indicated in the authorization.II. Your Rights

Following is a statement of your rights with respect to your PHI and a brief description of how you mayexercise these rights.

A. You Have the Right to Request a Restriction of Your Protected Health Information. Thismeans you may ask us not to use or disclose any part of your PHI for the purposes of treatment, paymentor healthcare operations. You may also request that any part of your PHI not be disclosed to familymembers or friends who may be involved in your care or for notification purposes as described in thisNotice of Privacy Practices. Your request must state the specific restriction requested and to whom youwant the restriction to apply.

We are not required to agree to a restriction that you may request. If we believe it is in yourbest interest to permit use and disclosure of your PHI, your PHI will not be restricted. If we agree to therequested restriction, we may not use or disclose your PHI in violation of that restriction unless it isneeded to provide emergency treatment. Please discuss any restriction you wish to request with ourPrivacy Officer(s).

B. You Have the Right to Receive Confidential Communications of PHI from us by AlternativeMeans or at an Alternative Location. We will accommodate reasonable requests. We may also conditionthis accommodation, if appropriate, by asking you for information as to how payment will be handled orspecification of an alternative address or other method of contact. We will not request an explanationfrom you as to the basis for the request. Please contact one of our Privacy Officer(s) to make such a request.

C. You Have the Right to Inspect and Receive a Copy of Your PHI. This means you may inspect and obtain a copy of your PHI that is contained in a designated record set for as long as we maintain thePHI. A “designated record set” contains medical and billing records and any other records that ourpractice uses for making decisions about you. Federal regulations require us to respond to your requestwithin thirty (30) days. We may charge a reasonable fee for copies of PHI (based on our costs), forpostage and for a custom summary or explanation of PHI. You will receive notification of any fee(s) to becharged before we release your PHI and you will have the opportunity to modify your request in order toavoid and/or reduce the fee.

You may not inspect or obtain a copy of the following records: psychotherapy notes;information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action orproceeding; and PHI that is subject to law that prohibits access to protected health information. Todiscuss your right to inspect and copy your PHI, please see one of our Privacy Officer(s).

D. You Have the Right to Have Your Physician Amend Your PHI. You may request that weamend your PHI in a designated record set for as long as we maintain this information. All requestsshould be in writing. Federal regulations require us to respond to your request within sixty (60) days.Please speak with one of our Privacy Officer(s) if you have any questions or would like to request anamendment of your PHI.

E. You Have the Right to Receive an Accounting of Certain Disclosures We Have Made, if any,of Your PHI. This right applies to disclosures for purposes including treatment, payment or health careoperations as described in this Notice of Privacy Practices. It also excludes disclosures we may havemade to you or for which we have an authorization from you and disclosures made to family members orfriends involved in your care. You have the right to receive specific information regarding thesedisclosures that occurred after April 14, 2003. The right to receive this information is subject to certainexceptions, restrictions and limitations. Federal regulations require us to respond to your request withinsixty (60) days. The first accounting in any 12-month period is without charge. We may charge you areasonable fee (based on our cost) for each subsequent accounting request within a 12-month period. If asubsequent request is received, we will notify you of any fee to be charged and will give you anopportunity to withdraw or modify your request in order to avoid or reduce the fee. Please contact one ofour Privacy Officer(s) to request an accounting.

F. You Have the Right to Obtain a Paper Copy of this Notice from Us. You have the right toreceive a paper copy of this notice upon request, even if you have agreed to accept this noticeelectronically.

G. Notification of Unauthorized Disclosure of Your PHI. You have the right to be notified whenthere is an impermissible or unauthorized access, acquisition, use and/or disclosure of your unsecuredPHI maintained by us or our Business Associates which compromises the security or privacy of the PHI.III. ComplaintsYou have the right to complain to us or to the Secretary of Health and Human Services if you believeyour privacy rights have been violated by us. You may file a complaint with us by notifying one of ourPrivacy Officer(s) in writing of your complaint. We will not take any action against you or deny youmedical care for filing a complaint. You may contact any of our designated Privacy Officer(s) at thephone numbers and offices listed on Page 1 of this notice for further information about the complaintprocess. Written complaints to the Secretary of Health and Human Services should be submitted to thefollowing address: Office for Civil Rights, U.S. Department of Health and Human Services, 150 S.Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111Effective Date: This Notice of Privacy Practices is effective on April 14, 2003.

PMA-039-2 AEL 12/2012

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Pa�ent Name ______________________________________________________DOB___________

I acknowledge that I have received a copy of the No�ce of Privacy Prac�ces for PMA Medical Specialists. If I wish to allow

anyone to receive my personal protected health informa�on, I must complete the Medical Record Release Authoriza�on Form.

Date: _________________ Pa�ent Signature _________________________________________________________________

(Must be 18 years of age or parent/legal guardian)

Signature of Parent or Legal Guardian _______________________________________________________________________

For Office use Only: � Pa�ent provided No�ce of Privacy Prac�ces but declines signature Date: _________________





MedicationRecordfor________________________________________

Address :_______________________________________________________________________________________________________

Primary Care Doctor: _______________________________________________ Ph #: ________________________________________

Other Doctor: ____________________________________________________ Ph # _________________________________________

Other Doctor: _____________________________________________________ PH # ________________________________________

Pharmacy : _______________________________________________________ Ph # _________________________________________

Health Condi�ons: _______________________________________________________________________________________________

Drug Allergies: __________________________________________________________________________________________________

Complete the reverse, by wri�ng down the name of each medica�on you take, the reason you take it, how you take it, and the form

(tablet, capsule, liquid), color and shape of the medica�on. In the last column, write down side effects and any special instruc�ons

your doctor or pharmacist have told you about. List all prescrip�on medica�ons and all over-the counter medicines, including

vitamins or other nutri�onal supplements, pain relievers, antacids, laxa�ves, and herbal remedies. Add new medicines when you

start taking them. Carry this list with you at all �mes in your purse or wallet. Show this form to your doctors whenever you have an

appointment. Bring this form with you to your pharmacy when you get a prescrip�on filled. You may want to make copies of the

blank form so you can use it again.

pmadoctor.com

Medica�on

Purpose/Reason Taken

Dose

Time(s) of Day

Form/Color/Shape

PMA Medical Specialists is commi�ed to providing all of our pa�ents with excep�onal care. When a pa�ent cancels

without giving enough no�ce, they prevent another pa�ent from being seen. Should you need to cancel or reschedule

an appointment, please contact our office as soon as possible. We require that you contact the office no later than

3pm on the day prior to your scheduled appointment to no�fy us of any changes or cancella�ons. To cancel a

Monday appointment, please call our office by 3pm the Friday before. This allows us �me to schedule other

pa�ents who are on a wai�ng list. We realize that emergencies do arise from �me to �me, however please try to give

us as much no�ce as possible when these situa�ons arise.

Medical Appointment Cancella�on/No Show Policy Effec�ve June 1, 2018

We do not receive compensa�on from insurance companies for a cancelled or no show appointment and these

occurrences prevent us from serving the needs of other pa�ents. To this end we have developed the following policy:

• 1st Missed Appointment without no�fica�on by 3pm the day before or Friday before a Monday appointment—

Pa�ent charged a No-show Fee of $25 (due before next appointment)

• 2nd Missed Appointment without no�fica�on by 3pm the day before or Friday before a Monday appointment—

Pa�ent charged a No-show Fee of $50 (due before next appointment)

• 3rd Missed Appointment without no�fica�on by 3pm the day before or Friday before a Monday appointment—

Pa�ent may be discharged from PMA Medical Specialists.

Should you experience extenua�ng circumstances, please contact the Office Manager, who will evaluate the situa�on.

I have read and understand the Medical Appointment/No Show Policy and agree to it’s terms.

AUDUBON | COLLEGEVILLE | LIMERICK | PHOENIXVILLE | POTTSTOWN | SCHWENKSVILLE

PrimaryCare| AllergyandClinicalImmunology| Cardiology| CriticalCareMedicine

DiabetesEducation| Electrophysiology| Endocrinology| Gastroenterology| NutritionalCounseling


Signature (Parent/Legal Guardian) Rela�onship to Pa�ent

Date Printed Name

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