Mental Health & Well-Being Registration

FOR TREATMENT

I, the undersigned, have voluntarily presented to Ibn Sina Foundation (ISF) for medical/or dental evaluation, diagnosis, and/or treatment. I consent and authorize my provider(s) or his or her designee(s) to provide diagnostic and therapeutic treatment, which may be necessary or advisable in their professional judgment. By signing this consent form, I do not waive my right to refuse recommended tests or treatment(s).

HIV CONSENT

I understand that during the time of treatment, health care workers may be exposed to the patients’ blood and/or body fluids increasing their risk of contracting Hepatitis B, Hepatitis C, and/or HIV. As part of my treatment, it may be requested that I be tested to determine if I have/had previous contact with the HIV, Hepatitis B, and Hepatitis C. This might be done as part of a diagnostic test or for hospital/or clinic infection control reasons. I understand the need for testing for these diseases and I agree to such testing of myself to promote the health and welfare of the health care worker.

RELEASE OF INFORMATION

I hereby authorize the ISF to use or disclose my protected health information acquired during my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment as described in the Notice of Privacy Practices. I authorize the release of medical information to my insurers as necessary for determination and payment of benefits; to healthcare providers involved in my care; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs. ISF may provide vaccination information to the state vaccine registry via electronic integration. I understand that my consent is not needed if the law requires ISF to report some aspect of my protected health information to a government agency (for example, suspected abuse, communicable disease and potential bodily harm to myself or others). I understand and acknowledge that ISF participates in an electronic medical record exchange program, and that if I seek treatment from other healthcare facilities or providers participating in this exchange program, my health information may be shared between ISF and those other facilities or providers for purposes of the delivery of care and services to me. I understand that my medication history will be retrieved for the last 12 months including medications I have filled through my prescription drug plan.

MEDICARE/MEDICAID PATIENTS

I authorize to release medical information about me to social security administration or its intermediaries for my Medicare/Medicaid/ Medigap claims. I assign the benefits payable for services to ISF.

NOTICE OF PRIVACY

HIPPA ACKNOWLEDGMENT: I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain patient rights regarding my protected health information. I understand that I have the right to review ISF Notice of Privacy Practices/Patients’ Rights and the most recent copy is available upon request. I understand that I may request restrictions be put on the use of my information, and to revoke my consent later. I understand that if I withhold consent for the use of my information for the purpose of treatment, payment or operations, ISF may refuse to undertake my care.

TREATMENT BY TRAINEES:

I understand that ISF takes part in education of medical/dental trainees and as such, services may be performed by individuals selected and deemed qualified by the attending physicians. Further, treatment and medical records may be reviewed by approved student and attending physicians for teaching purposes. I authorize residents /students to observe, cooperate, and participate in my care. 

GHH CONSENT:

ISF participates in Greater Houston Healthconnect (GHH), a non-profit organization that provides a secured electronic network for Healthconnect participants, including doctors’ offices, hospitals, labs, pharmacies, radiology centers and payers of health claims such as health insurers to share your protected health information. By signing this Authorization, you agree that GHH and its current and future participants may use and disclose your protected health information electronically through GHH for the limited purposes of treatment, payment, and health care operations. This authorization remains in effect unless and until you revoke it. You can revoke this authorization at any time by giving written notice to any healthcare provider who participates in GHH.

RESEARCH PARTICIPATION:

Ibn Sina community clinics participates in research studies which can involve proven or experimental treatments. 1 agree to participate and/or be contacted to participate in clinical research/advanced clinical care that would be beneficial for me and/or for other patients with a similar diagnosis. Information identifying patients will not be published without prior patient consent. I authorize residents /students to observe, cooperate, and participate in my care.

FILING A COMPLAINT:

Complaints about clinical care may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353.You may also contact Ibn Sina Foundation’s compliance manager by emailing at info@ibnsinafoundation.org or by calling at 281-977-7462 or by mailing at 11226 S Wilcrest Dr,  Houston, TX 77099. You will not be penalized for filing a complaint.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I also understand that by refusing to sign this complete consent or revoking this consent, this organization may rofiise to treat me