NEW PATIENT HEALTH HISTORY FORM FOR 4 YOU LLC.

1087 Mt. Vernon Ave. Marion, OH 43302 & 
562 W. Central Ave. Delaware, OH 43015

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE STRICTLY CONFIDENTIAL AND WILL BECOME PART OF YOUR MEDICAL RECORD.

Emergency Contact Information

Notice of Patient Privacy/Patient Consent Form

I understand that as part of my healthcare, the physicians of 4 You LLC. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. 4 You LLC. Notice of Privacy Practices provides specific information and complete description of how my personal information may be used and disclosed. I understand that a copy of the Notice of Privacy Practices is available at the front desk and understand that I have the right to review the notice prior to signing this consent. I understand that 4 You LLC. reserves the right to change the Notice of Privacy Practices. Prior to implementation of the revised Notice of Privacy Practices, there vised Notice will be mailed to me if I provide my address below. I understand I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that 4 You LLC. is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that 4 You LLC. has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact the person listed at the end of this document.

NOTE: 4 You LLC. must obtain your written authorization to use your Private Health Information for any purpose other than treatment or billing. If you want 4 You LLC. to have access to disclose your Private Health Information to your spouse or any other person during your treatment, please sign below.

Personal Health History

Alcohol 

Tobacco

Drugs

Sex

Family Medical History

Mental Health History

Other Problems

Health Information Portability and Accountability Act (HIPAA) 

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: · Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

Medical Records Release Request

I authorize the release of my medical records relevant to any treatment or copies of such and request that they be released to 4 You, LLC, Ashley Tincher, CNP, 1087 Mt.Vernon Avenue, Marion, Ohio 43302.