Patient Information Form

I understand that I have been advised by Dr. Vinas and his medical staff that smoking cigarettes as well as the use of all other products (Nicorette gum, patches, etc...) are harmful to patients contemplating or scheduled to undergo any surgical procedure.

I have been advised to stop smoking IMMEDIATELY, at most 2-4 weeks prior to any surgery.

lL understand that there are complications for any procedures, and these complications (delayed healing, and even loss of skin which could require skin grafting), could result from my surgery, in light of my history.

I acknowledge that I reviewed the above, initiated it, to signifying my understanding of the potential risks of my having this procedure while continuing to smoke cigarettes.

I give consent that LA Vinas, MD PA WPB can photograph or film me but only to the extent necessary and so long as the images are used solely for purposes of (a) identifying me as a patient or for purposes of documenting my health status, diagnosis and treatment while a patient; (b) conducting education and training, quality assurance and performance improvement functions for and on behalf of LA Vinas, MD PA WPB and its professional staff, and (c) publishing the results of my treatment on LA Vinas, MD PA WPB’s website which, in this particular case, required me to sign the HIPAA authorization form.

The purpose of this form 1s to obtain my prior written consent so that LA Vinas, MD PA WPB may photograph or film me for one or more of the following purposes listed below for which I do hereby consent.

Unless earlier revoked, this authorization will expire on the end of the treating physician's practice of surgery, except there will be no expiration for the purpose of medical or scientific research or use in specialty board examinations.

I also agree to sign the HIPAA authorization form which permits LA Vinas, MD PA WPB to use or disclosure these images but only to the extent permitted by HIPAA and other applicable laws and regulations.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain nghts and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

• Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
• It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
• The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
• You understand and agree to inspections of the office and review of documents which may include PHI by goverment agencies or insurance payers in normal performance of their duties.
• You agree to bring any concems or complaints regarding privacy to the attention of the office manger or the doctor.
• Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
• We agree to provide patients with access to their records in accordance with state and federal laws.
• We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
• You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office conceming your PHI. However, we are not obligated to alter internal policies to conform to your request.

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes if office policy. I understand that this consent shall remain in force from this time forward.