Dear New Patient, The Providers and staff would like to welcome and thank you for choosing and trusting Diabetes & Glandular Disease Clinic, P.A. with your health care needs. Our goal is to make your visits as pleasant and informative as possible. We understand the sensitive nature of your visit and respect your privacy. For these reasons, we are asking you to complete the enclosed new patient packet and mail or fax them to us prior to your first visit. Our direct confidential fax number is (210) 615-1083. If you are unable to complete the new patient packet prior to your visit, please bring it in completed at the time of your first visit. New patients are encouraged to register online at www.dgdclinic.com in order to have access to our patient portal where you can conveniently fill out the new patient packet at home instead of mailing, faxing or bringing it with you to your first appointment. As an established patient you will be able to access information in reference to future appointments, lab results, prescriptions and account billing summaries through our patient portal. If you were previously treated at another clinic or facility for the same care you will be receiving from our clinic, it is important to provide us with your records before your initial appointment. Since this can take up to four weeks, realize that not every patient will have their medical records available by the first visit. However, the quality of one's visit is enhanced when we have the ability to review your health records prior to your visit, especially when a patient has a medical history of diabetes/glandular disease. Please plan for your first appointment to be at least 45 minutes to an hour long. As a new patient, dependent on diagnosis and/or recommended treatment by your provider at the time of your first visit, you may be encouraged to attend a group class given by our Educators on staff. If applicable, the group class will be scheduled during your check out. Insurance and required demographic information to verify insurance is taken by our staff before your appointment is scheduled, Insurance information is verified within 2 days of your appointment. If insurance and required demographic information is not obtained, the appointment will not be confirmed and may be rescheduled. As a part of the patient information packet please know that payments all applicable fees, deductibles, coinsurance, or co-pays must be paid at the time of your visit. We accept cash, checks, Visa, MasterCard, and American Express. If patients are not able to pay their co-pay and/ or deductibles at the time of their appt., the patient's appointment will be rescheduled for a date when the patient is able to pay the co-pay and/ or deductible. Cancellations and Appointment Time is included in the packet. We encourage you to visit our website at www.dgdclinic.com for information about our providers and the services we provide. Thank you for choosing and trusting our providers and staff with your health care and we look forward to your first visit. For internal use only Pt's Acct. #: Pt's Name: 210.614.8612 Practice Phone 5107 Medical Drive San Antonio, Texas 78229 www.dgdclinic.com HIPAA Acknowledgment Form PATIENT ACKNOWLEDGEMENT Health Insurance Portability and Accountability Act (HIPPA) Our clinic's Notice of Privacy Practice provides information about how we may use and disclose protected health information about you, the patient. The Notice contains a Patient Rights sections describing your rights under the law. You have the right to review our Notice before signing this acknowledgment. The terms of our Notice may change, and if so, you may obtain a revised copy by contacting our office. The Summary of our Notice of Practices is posted in our main lobby. The complete Notice of Privacy Practices is also available in our main lobby for your review. If you would like to receive a copy of the Summary and complete Notice, we have one available for you at the front desk. If you wish for persons other than those released under normal operations, as indicated in the Notice, to receive confidential information that is now protected under this law, you must release them in writing. Please indicate on your patient registration form a spouse, or any family or friends whom you wish to be able to receive information about you. You may, of course, choose not to release anyone. You may also be more specific in your restrictions for the persons you have released, provided that the request is made in writing. Parents or Guardians of minors do not need to be released. Please be aware that our staff must follow federal law on information that we release by phone. We may at any time choose not to release information of any kind by phone if we deem the person requesting information is not authorized or that the information is too sensitive. By signing this form, you are acknowledging that the Diabetes & Glandular Disease Clinic has made our Notice of Privacy Practices available to you for review and that we have offered you a personal copy. Patient Name: Date of Birth: Signature: Acct.# This acknowledgment was signed by: Date: Printed Name (Patient or Representative) Relationship to Patient (if other than patient): For internal use onl

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