Medical Form

Name *

First

Last

Email *

Gender *

Male
Female

Date of Birth *

Height *

Weight *

Home Phone

Cell Phone *

Work Phone

Marital Status

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Referred by

In Case of Emergency

Name of friend or relative

Relationship

Home Phone

Work Phone

Allergy *

Yes
No

Have you ever had hormone therapy? *

Yes
No

When was your last treatment?

Did you have any problems?

What are your top 3 goals for Starting Hormone Replacement Therapy? *

Medications

Are you currently taking any other medications other than ones for Hormone/Testosterone Therapy? List each medication below

Additional Information

This section is for men only

Have you had a prostate exam? *

Yes
No

Have you had a recent wellness/physical exam? *

Yes
No

Have you been diagnosed with prostate cancer? *

Yes
No

Have you been diagnosed with breast cancer? *

Yes
No

Have you had prostate enlargement? *

Yes
No

Have you had any form of cancer? *

Yes
No

Do any of the following apply?

Have you noticed a decrease in your sex drive? *

Yes
No

Have you noticed a decrease in energy levels? *

Yes
No

Do you feel weaker or have less stamina? *

Yes
No

Do you feel tired all the time? *

Yes
No

Have you noticed decreased work performance? *

Yes
No

Are you more lethargic after dinner? *

Yes
No

Are your erections less hard? *

Yes
No

Are you prone to sadness or anger? *

Yes
No

Has your height diminished? *

Yes
No

Are you suffering from less vitality? *

Yes
No

Additional Information

Head Trauma

Yes

Cancer of any type

Yes

Heart disease or any heart related issues

Yes

HIV or related disease

Yes

High blood pressure

Yes

Immune deficiency of any type

Yes

Strokes

Yes

Skin disorders

Yes

Poor Circulation

Yes

Muscular or bone disorders

Yes

Edema or Swelling

Yes

Arthritis or autoimmune disorders

Yes

High Cholesterol

Yes

Disorder of the nervous system

Yes

Hormonal imbalance of any type

Yes

Seizure disorder

Yes

Sleep Apnea

Yes

Psychiatric disorders

Yes

Lung disorders

Yes

Psychiatric Hospitalizations

Yes

Clotting disorders

Yes

Depression

Yes

Digestive disorders

Yes

Vision disorders

Yes

Liver disorders

Yes

Hearing disorders

Yes

Hepatitis of any type

Yes

Upper respiratory, sinus disorders

Yes

Diabetes

Yes

Excessive snoring

Yes

Kidney disorders

Yes

Contagious condition

Yes

Bladder disorders

Yes

Illnesses contracted while abroad

Yes

Testicular or genital problems

Yes

Life threatening conditions

Yes

Physical defect or deformity

Yes

Genetic Disorders

Yes

Additional 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.

MultiCare Plus is committed to maintaining the privacy of your private health information (PHI). We keep records of the care and treatment you receive at our facilities, and those records contain your PHI. We are required by law to (i) maintain the privacy of your health information; (ii) provide you with this notice of our legal duties and privacy practices with respect to your health information; (iii) follow the terms of the notice of privacy practices currently in effect; and (iv) notify you if there is a breach of your health information. We must also provide you with the following important information: (a) how we may use and disclose your health information; (b) your privacy rights; and (c) our obligations concerning the use and disclosure of your health information.

This Notice explains generally how our clinic might share or disclose your health information. The privacy practices described in this Notice apply to all departments of our clinic, and will be followed by all employees, medical staff members, allied health professionals who have a need to use your health information to perform their job.

HOW WE MAY USE AND DISCLOSE INFORMATION ABOUT YOU We typically share or use your health information for the following reasons:

Treatment. We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, allied health professionals, nurses, technicians, or other facility personnel who are involved in taking care of you. Different departments of our clinic also may share health information about you in order to coordinate the different things you may need, such as prescriptions, lab work, and physicals. We may also disclose your health information to providers not affiliated with our clinic to facilitate care or treatment they may provide you. For example, we may disclose your health information to your personal physician(s) or other providers to whom you have been referred for care or who may participate in your care to ensure that your medical providers have the necessary information to provide proper treatment to you.

Payment. MultiCare Plus may use and disclose your health information in order to bill for services provided and collect payment. For example, we may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, including family members. We may also disclose your information to a collection agency to obtain overdue payment or to a regulatory agency to determine whether the services we provided were appropriately billed.

Business Associates. The clinic contracts with outside entities that perform business services for us, such as pharmacies, management consultants, quality assurance reviewers, accountants or attorneys. In certain circumstances, we may need to share your health information with a business associate so it can perform a service on our behalf. We will have a written contract in place with the business associate requiring protection of the privacy and security of your health information.

Appointment Reminders, Check-In and Results. MultiCare Plus may use and disclose your PHI to contact you to remind you of an appointment, billing or shipping. We will communicate with you using the information (such as telephone number (voice and/or text) and email address) that you provide. We may use a sign-in sheet at the registration desk and call you by name in the waiting room when your provider is ready to see you. We may also use your PHI to contact you about lab results. We may leave a voice or text message or send an email reminding you of an appointment or the results of certain tests but will leave the minimum amount of information necessary to communicate this information.

Treatment Options and Health-Related Benefits and Services. Our clinic may use and disclose your PHI to inform you of treatment options or alternatives as well as certain health-related benefits or services that may be of interest to you, using contact information you have provided.

Disclosures to Family or Friends. Our clinic may disclose your PHI to individuals involved in your care or treatment or responsible for payment of your care or treatment. If you are incapacitated, we may disclose your PHI to the person named in your Durable Power of Attorney for Health Care or your personal representative (the individual authorized by law to make health-related decisions for you), or to other family members or friends as we feel is in your best interest.

Law Enforcement. We may release health information at the request of law enforcement officials in limited circumstances, for example:

In response to a court order, subpoena, warrant, summons or similar process;
To identify or locate a suspect, fugitive, material witness, or missing person;
About the victim of a crime if, under certain limited circumstances, the victim is unable to consent;
About a death we believe may be the result of criminal conduct;
In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Legal Matters. We will disclose health information about you outside our clinic when required to do so by federal, state, or local law, or by the court process, such as in response to a subpoena or court order.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report reactions to medications or problems with products; notify people of recalls of products they may be using; track certain products and monitor their use and effectiveness; if authorized by law, notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and conduct medical surveillance of our facilities in certain limited circumstances concerning workplace illness or injury.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure of our facilities and providers. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Coroners, Medical Examiners. We may release Health Information to a coroner or medical examiner. In some circumstances this may be necessary, for example, to determine the cause of death.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent or lessen a serious threat to your health or safety, or the health or safety of the public or another person. Any disclosure, however, will be to someone who we believe may be able to help prevent the threat.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

Other Uses Requiring Authorization. Except for the permitted uses/disclosures noted above, most uses and disclosures of PHI for marketing purposes, uses and disclosures relating to highly confidential matters (such as abuse or neglect of a child, elderly person, or disabled adult, genetic testing, HIV/AIDS testing, diagnosis, or treatment, mental health, developmental disabilities, sexually transmitted diseases, or sexual assault), and disclosures that constitute the sale of PHI, require your written authorization.

Our clinic will obtain your written authorization for uses and disclosures that are not identified by this notice or otherwise required or permitted by applicable law. Any authorization you provide regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. However, your revocation will not affect actions we have already taken; in other words, we are unable to take back any disclosures of PHI we have already made.

YOUR PRIVACY RIGHTS REGARDING YOUR PHI

Although your health record is the physical property of the healthcare practitioner or clinic that compiled it, the information belongs to you. You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy some of the medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. When your medical information is contained in an electronic health record, as that term is defined in federal laws and rules, you have the right to obtain a copy of such information in an electronic format and you may request that we transmit such copy directly to an entity or person designated by you, provided that any such request is in writing and clearly identifies the person we are to send your PHI to. If you request a copy of the information, we may charge a fee for the costs of labor, copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy medical information in certain limited circumstances. If you are denied access to medical information, in some cases, you may request that the denial be reviewed per our review policy.

Right to Amend. If you feel that medical information, we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the clinic. You must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
Is not part of the medical information kept by or for the clinic;
Is not part of the information which you would be permitted to inspect and copy; or
Is accurate and complete.

Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures." This is a list of certain disclosures we made of medical information about you where an authorization was not required or obtained. The accounting will exclude disclosures for treatment, payment or health care operations, as well as other disclosures exempted by law. Your request must be in writing and state the time period for which you want the accounting (not to exceed six (6) years prior to the date you make the request). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within twelve (12) months. We will notify you of the costs involved with any additional request and you may withdraw your request before you incur any costs.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

We are required to agree to your request only if (1) except as otherwise required by law, the disclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and (2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not required to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will not ask you the reason for your request. To the extent we are reasonably able to comply, we will accommodate all reasonable requests.

Right to a Notice of Breach. You have the right to receive prompt notice in writing of a breach of your PHI that may have compromised the privacy or security of your information.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website or by contacting 610-588-2225.

Right to File a Complaint. If you believe your rights have been violated, you may file a complaint with us. To file a complaint, contact our clinic at 610-588-2225. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

CHANGES TO THIS NOTICE. We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted on our website and include the effective date. Revised 1/2021

CONTACT INFORMATION. If you have questions about this notice or your rights, or to file a complaint, you may contact:

MultiCare Plus 225 Erdman Avenue Bangor, Pa 18013 610-588-2225

As a patient you have the RIGHT to:

Be treated with courtesy and respect for your cultural, psychosocial, spiritual and personal values, beliefs and preferences, as well as with appreciation of individual dignity, positive self-image and protection of privacy and informational confidentiality within the law;
A prompt and reasonable response to questions and requests;
Know who is providing medical services and who is responsible for your care;
Know what patient support services are available;
Impartial access to medical treatment or accommodation regardless of race, national origin, religion, physical handicaps;

Know what rules and regulations apply to your conduct;

Be given information concerning the diagnosis, prognosis, planned course of treatment, benefits, risks and alternatives;
Request the clinic’s treating physician to consult with your primary care doctor and/or specialist when developing your plan of care;
Initiate or amend an advance health care directive and have clinic staff comply with those directives;
Refuse any treatment, except as otherwise provided by law;
Information about accessing protective services if you feel you are in physical danger, have been abused, harassed, neglected or exploited by anyone;
Be free from sexual, verbal, physical or mental abuse;
Receive, upon request, prior to treatment, price of charges for care;
Receive, upon request, a copy of reasonably clear and understandable itemized bill;
Express complaints or grievances through the office's Patient Coordinators, 610-588-2225

As a patient, you are RESPONSIBLE for:

Providing accurate and complete information about present physical complaints, past illnesses, hospitalizations, medications, and other matters relating to your overall health;
Reporting unexpected changes in your condition to your patient health coordinator or clinic;
Reporting your symptoms and working with the clinic staff and/or physician to manage your care;
Asking questions if you do not understand your treatment or what is expected of you;
Following the treatment plan recommended by the clinic staff and/or physicians;
Your actions if you refuse treatment or do not follow the patient health coordinators or physicians’ instructions;
Keeping appointments and, when you are unable to do so for any reason, for notifying the patient health coordinators or the clinic;
Providing accurate payment information to the clinic for the program;
Ensuring financial obligations of your health care are fulfilled as promptly as possible;
Complying with the clinics rules and regulations affecting patient care and conduct;
Being considerate of the rights of other patients and clinic personnel;
Being respectful of the property of the clinic and other patients;
All payments made to MultiCare Plus are non-refundable to cover administrative costs
If you decide to not move forward with the program, you will be responsible for Lab and physical costs. Monies that have already been paid to MultiCare Plus are to cover administration fees

I, the undersigned, do hereby agree and give my consent for treatment to MultiCare Plus (hereafter referred to as the Clinic) I hereby request and authorize MultiCare Plus, the physicians on its Medical Staff, assisted by the employees of the Clinic, to provide such care and administer such diagnostic, radiological and/or therapeutic procedures and treatments as, in the judgment of the physician(s), is deemed necessary or advisable in (my) the below patient’s care. This includes all routine diagnostic tests and procedures, including but not limited to diagnostic x-rays, the administration and/or injection of pharmaceutical products and medications and withdrawal of blood for laboratory examination purposes. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments and examination in the Clinic.

NOTICE OF PRIVACY PRACTICES: I acknowledge that I have received MultiCare Plus’s Privacy Practices, which describes the ways in which the Clinic will use and disclose my healthcare information for treatment, payment, and other described and permitted uses and disclosures. I understand that I may contact the Clinic if I have a complaint.

PATIENT RIGHTS: I acknowledge that I have been given information and instructions regarding my Patient Rights and Responsibilities, which include, but are not limited to, the right to make medical decisions, including the right to accept or refuse medical treatment, to participate in my plan of care and to receive care in a safe setting, free from verbal or physical abuse or harassment.

AUTHORIZATION TO OBTAIN/RELEASE INFORMATION FOR TREATMENT: By signing in the space below, I hereby authorize MultiCare Plus and the providers involved in my care and treatment to obtain medical information about me to assist in my care and treatment, and to make my medical information available to assist my other health care providers with my care and treatment. I understand that I can revoke authorization for this service at any time by contacting the Royal Medical Center office and completing a form to opt out.

RELEASE OF MEDICAL INFORMATION FOR PAYMENT PURPOSES: By signing in the space below as Patient, I hereby authorize the Clinic and the Physicians to release information and/or copies of my medical records to the Clinic, Physicians, Guarantor on my accounts, insurance companies, or government agencies for which I have assigned benefits for my treatment and care, and if requested, to my referring physician, or any other healthcare provider responsible for my care.

DIALING AND TEXTING DISCLOSURE STATEMENT: I authorize the Clinic and all of its related agents, business associates and independent contractors, permission to contact me regarding my care and treatment through the use of text messaging, dialing equipment or artificial voice, even if I am charged for the call/text. I expressly agree that such contact may be made by the Clinic and all its related agents. I expressly consent to such contact and with such consent, I specifically waive any claim I may have against the Clinic and all its related agents for making such calls, including any claim under the Telephone Consumer Protection Act.

GUARANTEE OF PAYMENT: I guarantee payment of any and all charges incurred during my visit(s) at the Clinic, to the Clinic and all its affiliates, attending and consulting physicians and allied health professionals. It is further agreed that if this account is referred for collection, I understand that I will pay the costs of collection including litigation costs and reasonable trial and appellate attorney’s fees. An itemized bill is available from the Clinic upon request by below patient.

I AGREE

NAME *