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SELECT SENIOR MEDICINE

3022 S. Morgans Point Rd, #261


Mount Pleasant, SC 29466
(843) 906-5534

PATIENT INFORMATION

Patient Name: ______________________________ Date of Birth: _____________ Sex: ____


Drivers License: _______________________ SSN: _________________________________
Home Phone: _________________________ Cell Phone: _____________________________
Address: ____________________________________________________________________
Do you have a health care power of attorney (POA)? yes

no

Name: __________________________________________ Relationship: _________________


Home Phone: _________________________ Cell Phone: _____________________________
Address: ____________________________________________________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: _________________________ Relationship: _________________
Home Phone: _________________________ Cell Phone: _____________________________
Address: ____________________________________________________________________
Emergency Contact Name: _________________________ Relationship: _________________
Home Phone: _________________________ Cell Phone: _____________________________
Address: ____________________________________________________________________
INSURANCE INFORMATION
Insured Party: _________________________ Relationship to Patient: ___________________
Insurance Company: ______________________________ Phone: _____________________
Address: ____________________________________________________________________
Policy Number: __________________________ Group Number: _______________________
Do you have a secondary insurance? yes

no

Insured Party: _________________________ Relationship to Patient: ___________________


Insurance Company: ______________________________ Phone: _____________________
Address: ____________________________________________________________________
Policy Number: __________________________ Group Number: _______________________
I verify that the above information is factual and true to the best of my knowledge. I authorize
the doctor to utilize radiology studies, lab tests, photographs, medicines, surgeries, and other
equipment or treatments that he/she deems necessary to provide proper patient care. I understand
that payment, proof of insurance, and/or copay is due at the time of service. I authorize this office
to apply benefits on my behalf for the covered services rendered. I certify that the insurance
information I have provided is factual and correct.

_____________________________________________ ______________________________
Patient
Date

SELECT SENIOR MEDICINE


3022 S. Morgans Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534

PATIENT CONSENT FORM

Patient Name: __________________________________ Date of Birth: _________________


Consent for Medical Treatment
I hereby authorize and request that Select Senior Medicine operated by Stephen Murk, M.D.
provide my medical care which may include, but not be limited to, examination, diagnostic
procedures, therapautic procedures, and treatments that are deemed necessary and advisable
in the judgment of the physician.
Authentication:
_____________________________________________

_____________________

Printed Name of Patient or Authorized Representative

Date

_____________________________________________

_____________________

Signature of Patient or Authorized Representative

Relationship, if applicable

Consent for Release of Information for Insurance Benefits


I hereby authorize Select Senior Medicine operated by Stephen Murk, M.D., upon rendering
treatment, to release to government agencies, insurance carriers, or others who are financially
liable for my care, all information needed to substantiate payment for my care.
Authentication:
_____________________________________________

_____________________

Printed Name of Patient or Authorized Representative

Date

_____________________________________________

_____________________

Signature of Patient or Authorized Representative

Relationship, if applicable

SELECT SENIOR MEDICINE


3022 S. Morgans Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534

HIPAA DISCLOSURE FORM

Patient Name: __________________________________ Date of Birth: _________________


Address: ____________________________________________________________________
Preferred Phone Number: ________________________

___ Home

___ Cell

Alternate Phone Number: ________________________

___ Home

___ Cell

Preferred Email Address: _______________________________________________________


May we identify ourselves over the phone? ___ Yes ___ No
May we correspond with you via email?

___ Yes ___ No

Please indicate where we may leave detailed messaged regarding appointments, billing, test
results, medication, and other treatment issues:
Preferred Phone Number

___ Yes ___ No

Alternate Phone Number

___ Yes ___ No

Email

___ Yes ___ No

I hereby authorize the doctor and/or hospital listed above to release my medical information
(appointments, lab/x-ray results, diagnoses, treatments, medications, surgeries, etc.) via postal
mail, telephone, fax, or email to the following family members:
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Authentication:
_____________________________________________

_____________________

Printed Name of Patient or Authorized Representative

Date

_____________________________________________

_____________________

Signature of Patient or Authorized Representative

Relationship, if applicable

SELECT SENIOR MEDICINE


3022 S. Morgans Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534

ACKNOWLEDGEMENT OF
RECEIPT OF NOTICE OF
PRIVACY PRACTICES

I, ______________________, have received a copy of this offices Notice of Privacy Practices.


_____________________________________________

_____________________

Print Name

Date

_____________________________________________

_____________________

Signature

Date

*You May Refuse to Sign This Acknowledgement*

Office Use Only


We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices
Acknowledgement could not be obtained because:
___ Individual refused to sign
___ Communications barriers prohibited obtaining the acknowledgement
___ An emergency situation prevented us from obtaining acknowledgment
___ Other (Please Specify)
________________________________________________________________________
________________________________________________________________________

SELECT SENIOR MEDICINE


3022 S. Morgans Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534

AUTHORIZATION
FOR RELEASE OF
HEALTH INFORMATION

Patient Name: __________________________________ Date of Birth: __________________


I, __________________________________, give permission for:
Patient Name

Name of Person, Provider, or Facility: _______________________________________________


Address: ____________________________________________________________________
Phone: ________________________________ Fax: ________________________________
to release my medical records to:
Stephen Murk, M.D.
Select Senior Medicine
3022 S. Morgan Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534
Types of Records Requested:
___ any and all types of records you have for this patient, or specify below
___ doctor visit notes

___ doctors orders

___ emergency room notes

___ nurses notes

___ urgent care notes

___ discharge summary

___ history and physical

___ lab reports

___ hospital progress notes

___ radiology reports

___ operation or procedure notes

___ consultations

___ clinic notes

___ other

___ pathology reports

________________________________

Comments: __________________________________________________________________
__________________________________________________________________________

Dates of Records Requested:


___ all dates, or specify time frame below
___ records dated between _________________________ and ___________________________

Certain information is covered by additional protection and requires specific authorization. To


authorize release or discussion of the following type of information, the person named above
must initial and date each item. If an item is not initialed and dated, the information, if such
information exists, cannot be released or discussed.
_______ ___________
Initial
Date
_______ ___________
Initial
Date
_______ ___________
Initial
Date

Alcohol or Drug Use/Abuse Treatment


Mental Health Treatment
HIV Status or Treatment

___________
From
___________
From
___________
From

___________
To
___________
To
___________
To

The named person has the following rights:

You may ask for and receive a copy of this authorization form.

This authorization will expire twelve months from the date you signed it. Additionally, you may
revoke authorization at any time by submitting a written request to this clinic or caretaker.

You have the right to inspect the information you are authorizing to be re-released.

The information you are authorizing to be released could be re-released or disclosed by


the recipient. Such additional disclosures or released may be prohibited by law. We are not
responsible for the actions of other who may be provided with information released as a result of
this authorization.

You may refuse to sign this authorization.

Authorization:
________________________________________________________________________________
Printed Name of Patient or Authorized Representative
_________________________________________________
Signature of Patient or Authorized Representative

______________________________
Date

_________________________________________________
Signature of Witness

______________________________
Date

SELECT SENIOR MEDICINE


3022 S. Morgans Point Rd, #261
Mount Pleasant, SC 29466
(843) 906-5534

NOTICE OF
PRIVACY PRACTICES

This notice describes how medical information about you may be used or disclosed and how you
can get access to this information. Please review it carefully.
Understanding Your Medical
Record/Health Information

your information in a certain manner or at a


certain location.
7. Revoke Your Authorization for Disclosure:
As your healthcare provider, we will maintain
You have the right to revoke an authorization
a record of your visit that contains a your
for disclosure of information that was
symptoms, reports of examinations and test
previously given.
results, diagnoses, treatments, correspondence
with other providers, and plans for future care or
Our Responsibilities
treatment.
Our practice is required to:
Your Heath Information Rights
1. Confidentiality: Maintain the privacy to your
Your health record is the physical property of this
health information.
practice; however, the information it contains 2. Provide a copy of this notice: We will provide
belongs to you. You have the following rights,
you with a copy of this notice of your legal
and we request that you notify the Office of
duties and privacy practices with respect
the Practice of your requests for any of these
to the information we collect and maintain
actions:
about you.
3. Abide by the terms of this notice.
1. Request Restrictions: You have a right 4. Unable to restrict: We will notify you if we are
to request restrictions on the use of your
unable to agree to a requested restriction of
information.
your information.
2. Obtain a Paper Copy of This Notice: You 5. Provide alternative means or alternative
have a right to receive a paper copy of this
locations: We will accommodate reasonable
notice.
requests you may have to communicate
3. Inspect and Copy: You have a right to inspect
health information by alternative means or at
and receive a copy of your health infortmation.
alternative locations.
If you request a copy of your information,
you may be charged a reasonable fee for We reserve the right to change our privacy
photocopying, retrieval, labor, postage, and practices and to make new provisions effective
supplies used.
for all protected health information we keep.
4. Amend: You have a right to request that we Should our information practices change, we
amend your health information.
will notify you of these changes when you return
5. Obtain an Accounting of Disclosures: You to our office. We will not use or disclose your
have the right to request an accounting of health information without your authorization,
certain disclosures of information that have except as described in this notice.
been made about you. This listing includes
those disclosures of your information other 1. If you have a question or would like additional
than treatment, payment, or healthcare
information, you may contact our office at
purposes and is within a specified period of
(843) 906-5334.
up to six years. The first listing of disclosures 2. If you have a concern about the privacy of
is provided as a complimentary service to
your information, you may contact our office.
you, but you may be charged a reasonable
Your concern will be responded to by our
fee for additional requests made within a
practice, but you may also file a complaint
twelve-month period.
with the secretary of Health and Human
6. Request Communications of Your Health
Services in the U.S. Office of Civil Rights.
Information: You have the right to request
The office will supply information about the
that you receive communications regarding
procedure.

Examples of Disclosures of Information


Treatment:
1. We will use your health information for
treatment purposes. As an example,
information given to a nurse or physician
will be recorded in your health record and
used to determine the best treatment for
you. Members of the healthcare team will
document your treatment goals, actions
taken, and clinical observations.
2. We will provide your other healthcare
providers with copies of various reports that
will help them to treat you for any subsequent
conditions that may arise.
Payment: A bill may be sent to you or a thirdparty biller. The information on our accompanying
bill may include information that identifies you,
your diagnosis, treatments, and supplies used.
Healthcare Operation: The physicians and
members of your healthcare team may use the
information to evaluate the quality of care you
received as well as the care received by others
similar to you. This information will be used to
improve the effectiveness of healthcare and
services we provide.
Business Associates: There are some
services provided through contracts with business
associates. As an example, we contract with a
company that provides information services for
the computer systems we operate. When these
services are contracted, we may disclose your
health information to this business associate so
that they can perform the work we require. To
protect your health information, the business
associate so that they can perform the work we
require. To protect your health information, the
business associate must appropriately safeguard
your information.
Notification: We may disclose information to
notify or assist in notifying a family member,
personal representative, or other person
responsible for your care, information about your
general condition.
Communication with Family: We will use good
judgment in disclosing to a family member or
any other person you identify health information
relevant to that persons involvement in your care
or payment related to your care.
Research: We will disclose limited information
only to approved researchers that participate
in research approval by our institutional review
board. We will obtain a written authorization from
you to disclose information for other research
purposes.

Funeral Directors: We may disclose health


information to funeral directors consistent with
state law that allows them to carry out their duties.
Organ Donation: If you are an organ donor, we
may disclose your information to organizations
that help procure, bank, or transport organs for
tissue donation and transplantation purposes.
Marketing: We may contact you to provide
appointment reminders or information about
treatment alternatives or other health-related
benefits and services that may be of interest to
you.
Fundraising: We may contact you as part of a
fundraising effort.
Food and Drug Administration: We may
disclose to the FDA health information relative to
adverse events with respect to food, supplements,
product and product defects, or post marketing
surveillance information to enable product recalls,
repairs, and replacements.
Workers Compensation: In accordance with
state law, we may disclose health information as
is required for processing a claim under workers
compensation.
Public Health: Under South Carolina law, we
may disclose your health information to the health
department in order to prevent or control disease,
injury, or disability.
Correctional Institution: If you are an inmate of
a correctional institution, we may disclose to the
institution or its agent health information that is
needed for your health or the health and safety of
other individuals.
Law Enforcement: We may discose health
information for law enforcement purposes as
required by law or in response to a valid subpoena.
Health Investigation: Federal and state laws
make provisions for your health information to
be released to appropriate health authorities
provided that a member of our staff or business
associate believe in good faith that we have
engaged in unlawful conduct or have otherwise
endangered one or more patients, workers, or
the public.
Other Disclosures: All other uses and disclosures
of your information will only be made with your
written authorization. If you have authrozied us to
use or disclose information about you, you may
revoke this authorization at any time.