This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box. Use common sense. For example. insomnia once last month probably isn't that important and would not be marked. However, Insomnia 1-2 times per week is notable and would be marked. Please take your time...
By documenting your email address on this page, you are agreeing that health information for yourself can be freely shared via email between yourself and Dr. David B Tuchinsky D.C. PLLC. While usually considered safe, email is not the most secure method of sharing personal information.
According to the Federal Food, Drug. and Cosmetic Act, as amended. Section 201 (g) (1), the term 'DRUG" is defined to mean:
"Articles intended for use in the Diagnosis. Cure, Mitigation, Treatment or Prevention of disease
A Vitamin is not a drug, NEITHER is a Mineral. Trace Element, Amino Acid, Herb, or Homeopathic Remedy.
Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented or be classified as a drug by anyone.
Therefore. please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.
Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.
Medical insurance is not accepted in our office for functional medicine and our office cannot assist you with a claim resolution. In addition, Dr. Tuchinsky does not submit notes or records to insurance companies.
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.
We are required by law to maintain the privacy of protected health information and must inform you of our privacy practices and legal duties. You have the right to obtain a paper copy of this notice upon request. We reserve the right to change the terms of the Notice at any time. Any changes will be effective for all protected health information that we maintain.
We have designated a privacy Officer to answer your questions about our privacy practices and to ensure that we comply with applicable laws and regulations. The Privacy Officer also will take your complaints and can give you information about how to file a complaint. Our Privacy Officer for the practice is David B. Tuchinsky, D.C., PLLC. You can contact the Privacy Officer at 800-371-0902.
Use and disclosure of your protected health information that we may make to carry out treatment, payment and healthcare operations.
We may use information in your records to provide treatment to you. We may disclose information from your record to help you get health care services from another provider, a hospital, etc. For example, if you want an opinion about your condition from a specialist, we may disclose information to that specialist to obtain that consultation. We may use or disclose information from your record to obtain payment for services that you receive. For example, we may submit a diagnosis with a health insurance claim in order to demonstrate to the insurer that the service should be covered. We may use or disclose information from your record to allow "health care operations". These operations include activities like reviewing records to see how care can be improved, contacting you with information about treatment alternatives and coordinating care with providers. For example, we may use information in your record to train staff about your condition or treatment.
You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment, payment or health care operations. However, we do not have to agree to these restrictions. You have the right to receive confidential communications from us. For example if you want to receive bills and other information at an alternate address please notify us. You have the right to inspect the information in your record, and may obtain a copy of it. This may be subject to certain limitations and fees. Your request must be in writing. If you believe information in your record is inaccurate or incomplete, you may request amendment of the information. You must submit sufficient information to support your request for amendment. Your request must be in writing.
You have the right to request an accounting of certain disclosures made by us.
You have the right to complain to us about our privacy practices. (Including the actions of our staff with respect to the privacy of your health information.) You have the right to complain to the Secretary of the Department of Health and Human Services about our privacy practices. You will not face retaliation from us for making complaints.
Except as described in this Notice, we may not make any use or disclosure information from your record unless you give your written authorization. You may revoke an authorization in writing at any time, but this will not affect any disclosure made by us before the revocation. In addition, if the authorization was obtained as a condition for obtaining insurance coverage the insurer may have the right to contact the policy or a claim under the policy even if you evoke the authorization.
Use of disclosure of your protected health information that we are required to make without your permission. In certain circumstances, we are required by law to make disclosure of your health information. For example, state law requires us to report suspected child abuse or neglect. Also, we must disclose information to the Department of Human Services, if requested, to prove that we are complying with regulations that safeguard your health information.
We may use or disclose information from your record if we believe it is necessary to prevent or lessen a serious and imminent threat to safety of a person or the public. We may report suspected cases of abuse neglect, or domestic violence involving adult or disabled victims.
Use of disclosure of your protected health information that we are allowed to make without your permission. There are certain situations where we are allowed to disclose information from your record without your permission. In these situations, we must use our professional judgment before disclosing information about you. Usually, we must determine that the disclosure is in your best interest and may have to meet certain guidelines and limitations.
We may assist in health oversight activities, such as investigations of possible health care fraud.
We may disclose information from your record as authorized by worker's compensation laws.
We may disclose information from your record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even if this is not ordered by a court.
Your provider or office staff may contact you to provide appointment reminders as a courtesy. However, you are responsible for remembering your appointment.
We may contact you with information about treatment alternatives or health related benefits or services that may be of interest to you.
INFORMED CONSENT REGARDING E-MAIL OR THE INTERNET USE OF PROTECTED PERSONAL INFORMATION
Dr. David B. Tuchinsky D.C., PLLC provides patients the opportunity to communicate with them by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail.
a. General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail to other recipients without the original sender(s) permission, or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten, or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history.
b. Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send, or receive e-mail from their place of employment risk having their employer read their e-mail.
2. It is the policy of Dr. David B. Tuchinsky D.C., PLLC that all e-mail messages sent or received, which concern the diagnosis, or treatment, of the patient will be a part of that patient's protected personal health information and we will treat such e-mail messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. Dr. David B. Tuchinsky D.C., PLLC will use reasonable means to protect the security and confidentiality of e-mail, or Internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail, or internet communications.
3. Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail included agreement with the conditions:
a. All e-mail to, or from, patients concerning diagnosis and/or treatment will be made a pert of the protected personal health information. As a part of the protected personal health information, other individuals and upon written authorization other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.
b. Dr. David B. Tuchinsky D.C., PLLC and his assistants may forward e-mail messages within the practice as necessary for diagnosis and treatment. We will not, however, forward the e-mail outside the practice without the consent of the patient, as required by law.
c. We will endeavor to read e-mail promptly, but can provide no assurance that the recipient of the particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency.
d. It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.
e. Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning diagnosis, or treatment of AIDS/HIV infection; other sexually transmissible, or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health, or developmental disability; or alcohol and drug abuse.
f. Dr. David B. Tuchinsky D.C., PLLC cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail, or internet communication. However, Dr. David B. Tuchinsky D.C., PLLC and his assistants are not liable for improper disclosure of confidential information not caused by it employee's gross negligence, or wanton misconduct.
g. If consent is given for the use of e-mail, it is the responsibility of the patient to inform Dr. David B. Tuchinsky D.C., PLLC staff of any type of information you do not want to be sent by e-mail.
h. It is the responsibility of the patient to protect their password or other means of access to e-mail sent, or received, from Dr. David B. Tuchinsky D.C., PLLC to protect confidentiality. Dr. David B. Tuchinsky D.C., PLLC is not liable for breaches of confidentiality caused by the patient.
Any further use of e-mail initiated by the patient that discusses diagnosis, or treatment, constitutes informed consent to the foregoing.
I understand that my consent to the use of e-mail may be withdrawn at any time by written communication to Dr. David B. Tuchinsky D.C., PLLC, firstname.lastname@example.org.
I have read this form carefully and understand the risks and responsibilities associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail.
Dr. David B. Tuchinsky, D.C., PLLC does not treat Chronic Acute Illness or other health
conditions but only provides advice to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological
and biomechanical process of the human body.
I also certify that no guarantee or assurance whatsoever has been made as the results that may be obtained nor any assurance or guarantee whatsoever to
cure any condition or illness.
I also understand while under the care of Dr. Tuchinsky, I need to also be under care of a medical professional monitoring my condition.
Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
Patient medical records
Live two-way audio and video
Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Responsibility for the patient care should remain with the patient’s local clinician, if you have one, as does the patient’s medical record.
Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physician consults and obtains test results at distant/other sites. More efficient medical evaluation and management. Obtaining expertise of a specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient, or at least a rescheduled video consult; Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information; In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities without my written consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had my questions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.