Aging Uneven Skintone - Heal n Cure · Do You have a Hormone Deficiency? TESTOSTERONE SIGNS &...

AgingUneven Skintone

Do You have a Hormone Deficiency?

TESTOSTERONE

SIGNS & SYMPTOMS (Men and Women)

I. My face has gotten slack and more wrinkled. 2. I've lost muscle tone. 3. My belly tends to get fat.4. I'm constantly tired. 5. I feel like making love less often than I used to.

SIGNS & SYMPTOMS (Men Only)

6. My breasts are getting fatty. 7. I feel less self-confidant and more hesitant. 8. My sexual performance is poorer than it used to be.9. I have hot flashes and sweats. I 0. I tire easily with physical activity.

ESTROGEN

SIGNS & SYMPTOMS

I. I am losing hair on top of my head. 2. I am getting thin, vertical wrinkles above my lips. 3. My breasts are droopy. 4. My face is too hairy. 5. I have hot flashes. 6. I feel tired constantly. 7. I am depressed. 8. My menstrual flow is heavy.

(0=moderate I 1-3=1ow / 4=none) 9. Women with periods: My cycles are irregular, too short

(<27 days),or too long (>31 days). I 0. Women without periods: I do not feel like

making love anymore.

PROGESTERONE

SIGNS & SYMPTOMS

I. My breasts are large. 2. My close friends complain I'm nervous and agitated. 3. I feel anxious. 4. I sleep lightly and restlessly.

NEVER

0 0 0 0 0

0 0 0 0 0

NEVER

0 0 0 0 0 0 0 0

0

0

NEVER

0 0 0 0

ALWAYS

2 3 4 2 3 4 2 3 4 2 3 4 2 3 4

2 3 4 2 3 4 2 3 4 2 3 4 2 3 4

ALWAYS

2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4

2 3 4

2 3 4

ALWAYS

2 3 4 2 3 4 2 3 4 2 3 4

The following questions are for women who have not yet reached menopause, and menopausal women who are taking hormone replacement therapy (estrogen or estrogen and progesterone).

5. My breasts are swollen and tender or painful before my O 1 2 3 4 period ...

6. My lower belly is swollen... 0 2 3 4 7. I'm irritable and aggressive... 0 2 3 4 8. I lose my self-control... 0 2 3 4 9. I have heavy periods... 0 2 3 4 I 0. My periods are painful. 0 2 3 4

THYROID

SIGNS & SYMPTOMS NEVER ALWAYS

I. I'm sensitive to cold. 0 2 3 4 2. My hands and feet are always cold. 0 2 3 4 3. In the morning my face is puffy and my eyelids are swollen. 0 2 3 4 4. I put on weight easily. 0 2 3 4 5. I have dry skin. 0 2 3 4 6. I have trouble getting up in the morning. 0 2 3 4 7. I feel more tired at rest than when I am active. 0 2 3 4 8. I am constipated. 0 2 3 4 9. My joints are stiff in the morning. 0 2 3 4 I 0. I feel like I'm living in slow motion. 0 2 3 4

DHEA

SIGNS & SYMPTOMS (Men and Women) NEVER ALWAYS

I. My hair is dry. 0 2 3 4 2. My skin and eyes are dry. 0 2 3 4 3. My muscles are flabby. 0 2 3 4 4. My belly is getting fat. 0 2 3 4 5. I don't have much hair under my arm. 0 2 3 4 6. I don't have much hair in the pubic area. 0 2 3 4

(0 = plenty of hair/ 4 = hairless) ?. I don't have much fatty tissue in the pubic area. 0 2 3 4

(flat"mound ofVenus"in women). (0 = padded/4 = flat) 8. My body doesn't have much of a special scent during 0 2 3 4

sexual arousal. 9. I can't t�erate noise. 0 2 3 4 I 0. My I ibid is low. 0 2 3 4

Add up your Overall Score Score for Women: S or less: Satisfactory level. Between 6 and 10: Possible Testosterone deficiency. 11 or more: Probable Testosterone deficiency. Score for Men: 10 or less: Satisfactory le':.tel. Between 11 and 20: Possible Testosterone deficiency. 21 or more: Probable Testosterone deficiency.

Add up your Overall Score Overall total of 10 or less is satisfactory level. Between 11-20: Possible Estrogen deficiency. 21 or more: Probable Estrogen deficiency.

Add up your Overall Score ____ _ Post-menopausal women not treated with hormone replacement therapy (estrogen or estrogen and progesterone): 4 or less: Satisfactory level. Between 5 and 8: Possible Progesterone deficiency. 9 or more: Probable Progesterone deficiency. Menstrual women and menopausal

women taking hormone replacement

therapy (estrogen or estrogen and

progesterone): 10 or less: Satisfactory level. Between 11 and 20: Possible Progesterone deficiency. 21 or more: Probable Progesterone deficiency.

Add up your Overall Score ____ _ Overall total is 10 or less is satisfactory level. Between 11-20: Possible Thyroid Hormone deficiency. 21 or more: Probable Thyroid Hormone deficiency.

Add up your Overall Score Overall total is 10 or less is satisfactory level. Between 11 -20:Possible DHEA deficiency. 21 or more: Probable DHEA deficiency.

Name ___________________________________________________________________________ Date ___________________________

GET RELIEF NOW

1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 10/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.

Patient Name: ______________________________________________________ Weight: _____________________

Patient Email: ______________________________________________________ Height: ______________________

Phone number: ___________________________ Date: ____________________ Goal Weight: _________________

I Want Relief From:

Cardiovascular Weight Management I Would Like To: p Heart Disease p Obesity (check all that apply)p Hypertension p Weight Distribution p Be Free of Pain p Chronic Inflammation p Be More Relaxed p Peripheral Vascular Disease Neurological p Burn More Body Fat p High Cholesterol p Migraines p Create a Wellness Lifestyle p Atherosclerosis p Risk of Stroke p Feel More Vital p Edema p Headaches p Get Less Colds and Flu p Get Rid of Allergies Musculoskeletal Gastrointestinal p Have More Energy p Fibromyalgia p Leaky Gut p Have More Muscle Tone p Joint Pain p Fatty Liver Disease p Improve Memory p Risk of Autoimmune Disease p Irritable Bowel Syndrome (IBS) p Improve Sex Drive p Inflammatory Arthritis p Heart Burn p Lose Weight (Rheumatoid Arthritis) p Ulcerative Colitis p Reduce Dependence on Meds p Inflammatory Arthritis (Lupus) p Crohn’s Disease p Reduce Risk - Degenerative Disease p Chronic Inflammation p Sleep Better Endocrine p Slow Down Aging Process Pulmonary p Hypothyroidism p Think More Clearly p Shortness of Breath p Type 2 Diabetes p Other: _______________________p Allergies p Metabolic Syndrome p Adrenal Fatigue _________________________________Men’s Health p Hashimoto’s Disease p Erectile Dysfunction _________________________________ p Decreased Libido Sleep p Hormone Replacement Therapy p Snoring _________________________________ p Sleep Apnea Women’s Health _________________________________p Polycystic Ovary Syndrome Kidney p Menopausal Symptoms p Risk of Chronic Kidney Disease _________________________________p Hormone Replacement Therapy p Infertility

Any other medical concerns that you need help with?: _________________________________________________

__________________________________________________________________________________________________

Medical Wellness & Weight Loss Center

Patient Medical History FormPt 1


Patient Name: ________________________________________ Date: ____________ Age: __________ Sex: F M

Present Status: 1. Are you in good health at the present time to the best of your knowledge? p Yes p No2. Are you under a doctor’s care at the present time? p Yes p No3. Are you taking any medications at the present time? p Yes p No

Prescription Drug/Dosage List All:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Over Counter Supplements/Dosage List All:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

4. Any allergies to any medications? p Yes p No Migraines? p Yes--Mediation? _____________ p No5. History of high blood pressure? p Yes p No 10. History of constipation? p Yes p No6. History of Diabetes? p Yes-what age?____ p No Difficult bowels, diarrhea, IBS? p Yes p No7. History of heart attack/chest pain/other? p Yes p No 11. History of glaucoma? p Yes p No8. History of swelling feet? p Yes p No 12. History of sleep apnea? p Yes p No9. History of frequent headaches? p Yes p No

13. Any other medical problems?

__________________________________________________________________________________________________

14. Gynecologic history: Number of pregnancies: _______ dates: _________________________________________________

Natural delivery or C-section: _________________________________________________________________________________

Complications with pregnancy (infertility, gestational diabetes, preeclampsia, high bp, other?: _________________________

__________________________________________________________________________________________________

Menstrual: Onset _____________ Duration _____________ Are cycles regular? p Yes p NoPain associated? p Yes p No Last menstrual period: _____________

Hormone replacement therapy? p Yes p No if yes, what type: ______________________________________________

Birth control pills? p Yes p No if yes, what type: ______________________________________________

Last check up: _________________________




Patient Name: ________________________________________ Date: ____________

15. Serious injuries/ List all ___________________________________________________________________________________

16. Any surgeries?/ List all ___________________________________________________________________________________

17. Toxin exposure: are you exposed to (circle applicable) Fumes / Strong odors / Gardening farming products

18. Family History: Age Health Disease Cause of death Overweight?

Father: ___________________________________________________________________________________________

Mother: ___________________________________________________________________________________________

Brothers: __________________________________________________________________________________________

Sisters: ___________________________________________________________________________________________Has any blood relative had any of the following and if yes, who? :

Glaucoma? p Yes p No __________________________ Asthma? p Yes p No _________________________

Epilepsy? p Yes p No __________________________ High BP? p Yes p No _________________________

Kidney disease? p Yes p No _________________________ Diabetes? p Yes p No ________________________

Psychiatric disorder? p Yes p No _____________________ Heart Disease/Stroke? p Yes p No _____________

Past Medical History: check all that applyp Polio p Jaundice p Kidneys p Lung Disease p Rheumatic Fever p Ulcers p Anemia p Tuberculosis p Drug Abuse p Pneumonia p Cholera p Arthritis p Measles p Mumps p Scarlet Fever p Gout p Whooping cough p Bleeding disorder p Heart valve disorderp Gallbladder disorder p Malaria p Eating disorder p Cancer p Osteoporosis p Tonsillitis p Pleurisy p Liver disease p Chicken pox p Nervous breakdownp Thyroid diseasep Alcoholism p Heart disease p Psychiatric illness p Typhoid fever p Blood transfusion

other ______________________________________________________________________________________________________

Nutrition Evaluation:

Present weight: _______ Height (no shoes): _______ Desired weight: _______ What time frame would you like to

be at desired weight? ___________________ Birth weight: _______ Weight at 20 years of age: _______

Weight one year ago: _______ What is the main reason for your decision to lose weight? ____________________

__________________________________________________________________________________________________

When did you begin gaining excess weight? (give reasons if known) _____________________________________

__________________________________________________________________________________________________





Nutrition Evaluation Continued: What has been your maximum lifetime weight (non-pregnant) and when? __________________________________________

Previous diets followed / Dates / Results: ______________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Is your significant other overweight? p Yes p No If yes, by how much? ________________________________________

How often do you eat out? ____________________________________ What restaurants? _____________________

__________________________________________________________________________________________________

How often do you eat fast food? _______________________________________________________________________

Who plans meals? _____________________Cooks? _____________________Shops?_____________________Do you use a shopping list? p Yes p No What time of day and what day of week do you usually shop for groceries? _________________________________________

Food allergies? _______________________________ Food dislikes? _______________________________________________

Foods you crave: ___________________________________________________________________________________________ Any specific time of day or month when you crave food? _________________________________________________________

Do you drink coffee or tea? p Yes p No If yes, how many per day? _________________________

Do you drink soda/juice/flavored water? p Yes p No If yes, how much daily? _________________________

Do you drink alcohol? p Yes p No What type, how much, how often? _______________________________________

Do you use substitute for: sugar? _______________________ butter? _______________________

Do you wake hungry during the night? p Yes p No What do you do? ________________________________________

What are your worst food habits? ______________________________________________________________________________Snack Habits:What? _________________________________ How much? _________________________________ When? _________________

_________________________________ _________________________________ _________________ When you are under a stressful situation at work or family related, do you tend to eat more? Explain?

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________





Are you currently under a stressful situation or emotional upset? Explain: _______________________________________

____________________________________________________________________________________________________________

__________________________________________________________________________________________________

Smoking habits (answer one only): p Never smoked p Quit smoking (how many years ago _______) p Quit cigarettes and smoke only cigars or pipe without inhaling smoke p Smoke 20 per day (1 pack) p smoke 30 per day (1 1/2 packs) p smoke 40 per day (2 packs)

Typical Breakfast Typical Lunch Typical Dinner

_________________________________ _________________________________ _________________________________

_________________________________ _________________________________ _________________________________

_________________________________ _________________________________ _________________________________

Time eaten: ______________________ Time eaten: ______________________ Time eaten: ______________________

Where/with: ______________________ Where/with: ______________________ Where/with: ______________________

Describe your usual energy level: ______________________________________________________________________________

Activity level (answer only one):p Inactive- no regular physical activity with a sit down job p Light activity- no organized physical activity p Moderate activity- occasionally involved ie; weekend golf, tennis, jogging, swimming, cyclingp Heavy activity- consistent lifting, stairs, heavy construction, regular jogging, swimming, cycling, sports 3x week p Vigorous activity- extensive physical exercise at least 1 hour sessions 4x per week

Behavior style (answer only one):p Always calm and easygoing p Usually calm and easygoing p Sometimes calm with frequent impatience p Seldom calm and persistently driving for advancement p Never calm and have overwhelming ambition p Hard driving and can never relax

Please describe your general health goals and improvements you wish to make: _________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

This information will assist us in assessing your particular problem areas and establishing your medical management. Thank you for your time and patience in completing this form.


It is your responsibility to know if your insurance has specific rules or regulations, such as the need for refer-rals, recertification’s, preauthorization’s, limits on outpatient charges, specific physicians and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payers regardless of whether or not our physicians participate.

The responsibility for payment of fees for services is your direct responsibility. Your health benefit plan is an arrangement between you, the enrollee, and the insurance company or your employer. We will do our best to assist you with understanding your proposed treatment and in answering questions related to your insurance.

We require you to provide us with 24 hour notice for prescription refill during the weekday. The requests made over the weekends and holidays will be filled the following business day. We need minimum of five day notice to fill out any paperwork.

Should you have any questions with regard to our financial policy we encourage you to ask.

We ask that you present the correct and updated contact and medical insurance information at the time of each visit. Please notify the receptionist of any changes during the subsequent visits promptly.

The office requires at least 24 hours’ notice when canceling an appointment. Failure to provide this notice will result in a charge of up to $75.00

No refunds are allowed under any circumstances.

Individual results vary. There are no guaranteed results.

Fee per current Illinois State Auditor guidelines (Minimum $25.00)

Accounts are sent to collection 60 days after the due date. This results in an automatic termination from the practice. A 25% collection fee and 10% annual interest is added to the amount due.

Payment Policy Schedule*

Full payment due at time of service

Other charges/fees* Full payment due at time of service

* subject to change at any time

No refunds or guarantees

FINANCIAL POLICY



☐ Copayments ☐ Deductible and coinsurance

☐ Non-covered service ☐ Nonparticipating insurance plan

☐ Return Check Fee $25.00

☐ Cancellation/ MissedAppointment Fee

☐ I have read and I understand the Heal n Cure Financial Policy.

☐ No refunds

☐ No guarantees

☐ Medical Records

☐ Collection Charges

______________________________________ Patient Signature

______________________________________ Date

Wellness Weight Loss Family Medicinel l

Please check all boxes below to acknowledge you have read the financial policy

7

PATIENT REGISTRATION


Last Name: ____________________________ First Name:___________________________________ MI: ________

Address: _____________________________ City, State, Zip: _____________________________________________

Home #:( ) ____________________ Work #:( ) ___________________ Cell #:( ) ___________________

Social Security #: __________________ Date of Birth: ____________________ Age: _________________________

Gender: M F Marital Status: __________________ Email: _____________________________________________

How did you hear about our practice? ______________________________________________________________

Would you like to subscribe to our newsletter? Yes ___ No ___

I have come to Heal n Cure based upon my interest in (mark all that apply):

INSPIRE (medically supervised weight loss program) ___ BLISS (lipo-laser treatment) ___

LUSTRE (aesthetic laser treatment) ___

*Complimentary Consults with Lifestyle Educators are available for additional information about our programs.

Employment Information:

Employer: ____________________________________________ Occupation: _______________________________


Phone #:( ) ____________________

Emergency Contact :

Name: _________________________________ Relation: ______________ Phone #:( ) ____________________

Secondary Emergency Contact :

Name: _________________________________ Relation: ______________ Phone #:( ) ____________________

Primary Care Provider (PCP):

PCP Doctor: ______________________________________________________________________


Phone #:( ) ____________________ Fax #:( ) ____________________

Office Use NPI: _____________________________

PATIENT REGISTRATIONPHARMACYPRESCRIPTION HISTORY


Booking Future Appointments:For our patient’s convenience, booking, rescheduling and managing your next appointment with Heal n Cure can be accomplished in person at our office, by phone (847)-686-4444.

Statement of Acknowledgement:

I certify that information provided is true and accurate. I understand and agree that, regardless of my insur-

ance status, I am ultimately responsible for the balance of my account. I authorize payment of medical ben-

efits to Heal n Cure when assignment has been taken. I have read the office financial policy and agree to all

terms and conditions. I authorize Heal n Cure to use or disclose any information for treatment, payment, and

healthcare operations. I authorize that the physicians and/or employees of Heal n Cure can contact me via all

necessary means (phone, email, fax, etc) or leave me a message if they are unable to contact me directly. I

acknowledge that I have received a copy of the Notice of Privacy Practices.

Preferred Pharmacy: Name, address, phone, fax:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Prescription History Consent

I, (printed name)_____________________________ , give consent to Heal n Cure to access my previous prescriptions.

Signature ______________________________________________________________ Date: ___________________

Heal n Cure, SC Meena Malhotra, MDwww.healncure.com Phone: 847-686-4444

Fax: 847-686-9999

Acknowledgement Of HIPAA Laws

I_________________________, herby acknowledge the receipt and complete understanding of Notice Of Privacy Practices of Heal n Cure, SC which provides detailed information about how the practice may use and disclose my confidential information.

I understand that Heal n Cure has reserved the rights to change its privacy practices that are described in the Notice. I also understand that a copy of any revised notice will be provided to me or made available at the subsequent visit to the clinic.

Signature: _____________________________ Date: ________________

If you are not the patient, please verify your relationship to the patient.

Relationship to Patient:___________________

Signature: _____________________________ Date: ________________

1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.com Copyright © 2016 Heal n Cure SC. All Rights Reserved. Do not reproduce without written permission.

10

http://www.healncure.com/

Revised 01/17

Patient Name: Patient DOB: Patient MRN:

Date :

Depression Screening and Management GuidelineScreen every 2 years for chronic illness or wellness patients No Yes During the past two weeks, have you ever felt down, depressed or hopeless? During the past two weeks, have you felt a lack of pleasure or interest in doing things?

YES (to both) – Answer the following DSM IV Criteria: No Yes NO (to both) 1. Depressed mood most of the day, nearly every day Re-screen at 3 and 6 months 2. Markedly diminished interest or pleasure in almost all activities

most of the day, nearly every dayfor post-MI and every 2 years for all

others 3. Significant weight loss or weight gain4. Insomnia / hypersomnia5. Psychomotor agitation / retardation6. Fatigue (loss of energy)7. Feelings of worthlessness (guilt)8. Impaired concentration (indecisiveness)9. Recurrent thoughts of death or suicide

No Yes IS THERE A DOMINANT SECONDARY ETIOLOGY? (e.g., meds / thyroid abnormality)

Treat

IS THERE ASSOCIATED PSYCHOSIS OR MANIA?

IS THERE SUICIDAL IDEATION? (send to emergency room if acutely suicidal)

TREAT WITH HEART SAFE SSRI: SERTRALINE: mg Treat and/or CITALOPRAM: mg Consider

OTHER: mg Behavioral Health Referral

REASSESSMENT AT 6 WEEKS SHOWS IMPROVEMENT?

WOULD LIKE 2ND OPINION / RECOMMEND PSYCHOTHERAPY?

BEHAVIORAL HEALTH RESOURCE NETWORK Direct Referral for Non-Urgent Care: HMOI/BA : 800-346-3986 Blue Medicare Advantage: 800-753-5456

Aetna: 800-342-5840 or ID Card Cigna: 800-541-7526 or ID Card Humana: 800-331-9040 Unicare: 800-746-6294

Heal n Cure Wellness. Weight Loss. Family Medicine

Patient Name: Chart Number: - - - - - - - - - - - - - - -- - - - - - - - - - - -

The following questions ask about your eating patterns and

behaviors within the last 3 months. For each question, choose

the answer that best applies to you.

1. During the last 3 months, did you have any episodes of

excessive overeating (i.e., eating significantly more than

what most people would eat in a similar period of time)?

Yes

NOTE: IF YOU ANSWERED "NO" TO QUESTION 1, YOU MAY STOP.

THE REMAINING QUESTIONS DO NOT APPLY TO YOU.

2. Do you feel distressed about your episodes

of excessive overeating?

Within the past 3 months ...

3. During your episodes of excessive

overeating, how often did you feel like

you had no control over your eating (e.g.,

not being able to stop eating, feel

compelled to eat, or going back and

forth for more food)?


overeating, how often did you continue

eating even though you were not hungry?


overeating, how often were you

embarrassed by how much you ate?


overeating, how often did you feel

disgusted with yourself or guilty afterward?

7. During the last 3 months, how often

did you make yourself vomit as a means

to control your weight or shape?

Never

or Sometimes

Rarely

This information is brought to you by Shire US Inc.

Yes

Often

No

No

Always

1122 Willow Road I Northbrook, IL 600621 Tel 847.686.44441 Fax 847.686.99991 www.healncure.com Copyright© 1/17 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission.

Date: ___________________________

12

PRIVACY NOTICE

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.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all records of your care generated and maintained by Heal n Cure, SC. Your hospital or non-Heal n Cure, SC providers may have different policies or notices about the use and disclosure of information in their possession.

We are required by law to: 1) make sure that medical information that identifies you is kept private; 2) make available to you this Notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

• We may disclose medical information about you to doctors, nurses, medical students, or otherHeal n Cure, SC personnel involved in taking care of you. We may also disclose medicalinformation to people outside the medical group, such as family members, specialists or otherswho are involved in providing services that are part of your care after the appropriateemergency contact, medical releasae, HIPAA compliant forms have been completed andsigned by you.

• We may use or disclose medical information about you so that the treatment and services youreceive at Heal n Cure, SC may be billed to and payment may be collected from you, aninsurance company or a third party.

• We may use or disclose medical information about you for Heal n Cure, SC operations. Thesemay include use of information to evaluate the performance of our staff, effectiveness ofprograms, and ways to improve care and services we offer. These uses and disclosures arenecessary to ensure that all of our patients receive quality care.

• We may use and disclose medical information to contact you as a reminder that you have anappointment for treatment or care at Heal n Cure, SC.

• We may use or disclose medical information to tell you about or recommend possibletreatment options or alternatives, and about health-related benefits and services that may be ofinterest to you.

• We may disclose medical information about you to other healthcare providers in the event youneed emergency care.

• We will disclose medical information about you as required by federal, state or local law.• We may use or disclose medical information to a public health organization or federal

organization when necessary to prevent a serious threat to your health and safety or the healthand safety of the public or another person.

• We may use or disclose medical information about you in special situations such as forworkers' compensation programs, as required by military command authorities or theDepartment of Veterans Affairs, in response to a court or administrative order, or for publichealth activities.

• Other uses and disclosures of medical information not covered by this Notice or the laws thatapply to us will be made only with your written authorization. You may later revoke thispermission in writing, at any time.

1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 10/2017 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission. 1

PATIENT COPY

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

• You have the right to review and receive a copy of medical information that maybe used to make decisions about your care. Usually this includes medical andbilling records, but does not include psychotherapy notes. You must submit awritten request to review and copy your medical information. We may charge afee for the costs of supplying a copy of the records.

• You have the right to ask us to amend medical information that you feel isincorrect or incomplete. Your request for an amendment must be submitted inwriting and must provide a reason that supports your request.We may deny your request for amendment if it is not in writing or does notinclude a reason to support the request. In addition, we may deny your request ifthe information: 1) was not created by us; 2) is not part of the medical informationkept by or for Heal n Cure, SC; 3) is not part of the information which you arepermitted to inspect and copy; or 4) is accurate and complete.

• You have the right to request an "accounting of disclosures." This is a list ofdisclosures we have made of medical information about you, with someexceptions. The exceptions are governed by federal health privacy law, andinclude: 1) routine disclosures for treatment, payment and operations conductedpursuant to your signed consent form; and 2) disclosures to you. You mustsubmit a written request. The request must state a time period that may not belonger than six years and may not include dates before April 14, 2003, whencurrent federal health privacy laws become effective for Heal n Cure, SC.

• You have the right to request restrictions or limitations on the use or disclosure ofmedical information about you. You must submit a written request for restrictionthat specifies: 1) what information you want to limit; 2) whether you want to limitour use, disclosure, or both; and 3) to whom you want the limits to apply. Heal nCure, SC reserves the right to refuse your restriction if it is in conflict of providingyou quality healthcare or in an emergency situation.

• You have the right to request that we communicate with you about medicalmatters in a certain way or at a certain location, such as only at work or by mail.

• You must submit a written request for confidential communications restrictions,specifying how or where you wish to be contacted. We will accommodatereasonable requests.

• You have the right to possess a copy of this Privacy Notice upon request. Youmay receive a paper copy of this notice, or you can also obtain a copy of thisNotice at our website, www.healncure.com.

• You have the right to file a complaint with Heal n Cure, SC if you believe yourrights to privacy have been violated. All complaints must be submitted in writingto the Office Manager at our clinic address. All complaints will be investigated. Nopersonal issue will be raised for filing a complaint.

1122 Willow Road | Northbrook, IL 60062 | Tel 847.686.4444 | Fax 847.686.9999 | www.healncure.comCopyright © 10/2017 Heal n Cure SC. All Rights Reserved. Confidential & proprietary. Do not reproduce without written permission. 2

CHANGES TO THIS NOTICE

Heal n Cure, SC reserves the right to change this Notice at any time. We will post a copy of the current notice in our clinic and on our website.

Aging Uneven Skintone - Heal n Cure · Do You have a Hormone Deficiency? TESTOSTERONE SIGNS &...

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