Name: William M. Jacobsen, MD FACS
Address: 2525 E Arizona Biltmore Cir #C236, Phoenix, AZ, 85016, US
Telephone: (602) 212-0100

ONLINE PATIENT REGISTRATION FILLABLE FORM
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ADDITIONAL CONTACT (Parent/Guardian If Patient Is Under Age of 18)
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INSURANCE INFORMATION
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PHYSICIAN INFORMATION
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PHARMACY INFORMATION
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This is a fill in the Pharmacy Street Address* field. Please add appropriate Pharmacy ZIP Code* fields and text.
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Need exact address/zip not cross streets please!
ALLERGIES (PLEASE SPECIFY ALL MEDICAL ALLERGIES)
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I have no known drug allergies
Please list all known drug allergies, or click NKDA above if none
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MEDICATIONS
Are you currently taking any of these BLOOD THINNER Medications?
Please select any of the following drugs you are currently taking. CLICK NONE BELOW if you are not taking any blood thinners
Advil Aggrenox Aleve Brilinta Coumadin/Warfarin Effient Fragmin Heparin Ibuprofen Lovenox Motrin Naprosyn Eliquis Plavix Pradaxa Warfarin/Coumadin I TAKE NO BLOOD THINNERS !!!
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HISTORY
Your Weight in lbs *
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Do you have a pain management physician *
Yes No
Name of Pain Management Physician
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Do you have any medical problems? *
Angina Asthma Bleeding Breast Cancer Diabetes Heart Attack High Blood Pressure Kidney Failure Lung Disease Seizures Skin Cancer I HAVE NO MEDICAL PROBLEMS OF SIGNIFICANCE
Have you ever had? *
Heart Attack? Cardiac Stent? Heart Surgery? Atrial Fibrillation? Pacemaker? Defibrillator? Congestive Heart Failure? Pulmonary Embolus? Deep Vein Thrombosis? Blood Clots? I HAVE HAD NONE OF THESE MEDICAL PROBLEMS
Please list any additional medical problems
SECTION 1: LEGAL, ATTORNEY, INSURANCE OPINIONS, FORMS OR LETTERS
DR. JACOBSEN DOES NOT WISH TO DISAPPOINT YOU IF THE INTENT OR ANY PORTION OF THE INTENT OF YOUR CONSULTATION IS TO OBTAIN ANY OF THE FOLLOWING: OPINION, MEDICAL EXPERT, WITNESS, LETTER OR DOCUMENT RELATED TO LEGAL CLAIMS, YOUR LAWYER’S INSTRUCTIONS OR NEED FOR DOCUMENTATION RELATED TO ANY INJURY OR SURGERY DONE ELSEWHERE. PLEASE INFORM OUR STAFF BEFORE YOU SEE DR. JACOBSEN SO THEY CAN IMMEDIATELY HELP YOU FIND AN ALTERNATIVE PLASTIC SURGEON FOR CONSULTATION. DR. JACOBSEN DOES NOT PARTICIPATE AND WILL NOT ENGAGE IN LEGAL MATTERS EITHER DURING OR AFTER YOUR CONSULTATION AND WILL NOT COMMUNICATE WITH YOUR LEGAL REPRESENTATIVES IN THESE MATTERS.
FEE SCHEDULE: YOU OR YOUR ATTORNEY MAY REQUEST COPIES OF YOUR PHOTOS/CD FOR A REPRODUCTION FEE OF $250.00. A COPY OF YOUR MEDICAL RECORDS WILL BE GLADLY PROVIDED TO YOU OR YOUR ATTORNEY AT YOUR REQUEST FOR LEGAL OR MEDICAL PURPOSES FOR A REPRODUCTION FEE OF $100.
FORM COMPLETION: DR. JACOBSEN AND HIS STAFF WILL NOT COMPLETE WORK-RELATED OR DISABILITY FORMS UNTIL YOU HAVE BECOME OUR VALUED PATIENT, HAVE HAD SURGERY, ARE KIND AND GRACIOUS TO OUR STAFF AND FILL OUT ALL THE BOXES ON THE FORM THAT YOU CAN. THEN DR JACOBSEN WILL FILL IN THE MEDICALLY RELATED INFORMATION AND SIGN IT FOR YOU. WE WILL NOT FILL OUT ENTIRELY BLANK FORMS. YOU MUST DO YOUR BEST TO FILL OUT WHAT YOU CAN AHEAD OF TIME.
PLEASE SIGN BELOW TO INDICATE YOUR UNDERSTANDING THESE LIMITATIONS OF DR. JACOBSEN’S SERVICES.
Digital Signature for Section 1 (use your mouse cursor to draw your signature in the space provided).

I understand Dr Jacobsen does not give legal or insurance quotes or opinions and will notify Dr Jacobsen's staff if this is in whole or part of my reason for coming to consult with Dr Jacobsen Clear
Date
Month Day Year
SECTION 2: CONSENT TO TAKE PHOTOGRAPHS
I HEREBY AUTHORIZE WILLIAM M. JACOBSEN, M.D. AND/OR HIS ASSOCIATES OR LICENSEES TO TAKE PRE-OPERATIVE, INTRA-OPERATIVE, AND POST-OPERATIVE PHOTOGRAPHS AND/OR VIDEOS. THESE PHOTOGRAPHS ARE IMPORTANT FOR MY PATIENT CARE AND NECESSARY FOR ANY PROCEDURE, TREATMENT OR SURGERY PERFORMED BY DR. JACOBSEN. I UNDERSTAND DR. JACOBSEN WILL PROTECT MY PRIVACY AND KEEP THESE PHOTOGRAPHS PRIVATE AND SECURE AS A PART OF MY MEDICAL RECORD. I UNDERSTAND DR. JACOBSEN WILL NOT SHARE MY PHOTOGRAPHS OR USE MY PHOTOGRAPHS FOR ANY OTHER PURPOSE UNLESS A SEPARATE AGREEMENT FOR MY PERMISSION IS GRANTED AND SIGNED.
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I consent to allow Dr Jacobsen to take my photograph for my medical care only Clear
Date
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SECTION 3: CONSENT NOT TO TAKE PHOTOS IN DR JACOBSEN'S OFFICE
I AGREE THAT I WILL NOT TAKE ANY PHOTOS, VIDEOS, OR MAKE ANY RECORDINGS OF DR. JACOBSEN OR HIS OFFICE WITHOUT RECEIVING HIS PRIOR VERBAL PERMISSION.
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I will not use cameras within Dr Jacobsen's office without his permission Clear
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SECTION 4: MALPRACTICE EXPERT AGREEMENT
DR. JACOBSEN TAKES GREAT PRIDE IN OUR REPUTATION FOR PROVIDING THE HIGHEST LEVELS OF QUALITY SURGICAL CARE TO OUR PATIENTS. HOWEVER, WE REALIZE THERE MAY BE TIMES WHEN SOME PATIENTS WILL NOT BE SATISFIED WITH THE OUTCOMES OF THEIR TREATMENTS. WE ALSO RECOGNIZE THAT IN THESE INSTANCES, A PATIENT HAS EVERY RIGHT TO PURSUE LEGAL ACTION IF HE/SHE FEELS DR. JACOBSEN HAS BEEN NEGLIGENT IN SOME WAY. WE RESPECT EVERY PATIENT’S RIGHT TO DO SO. WHILE SOME HEALTHCARE LEGAL CLAIMS ARE JUSTIFIED, THERE ARE ALSO FRIVOLOUS LEGAL CLAIMS FILED IN OUR COUNTRY. THESE CLAIMS ARE DRIVING UP INSURANCE RATES AND HEALTH CARE COSTS. THESE FRIVOLOUS ACTIONS ARE IMPACTING COURT DECISIONS FOR THE PATIENTS WHO TRULY DESERVE COMPENSATION. THESE FRIVOLOUS ACTIONS ARE MAKING ACCESS TO CARE FOR SOME PATIENTS IN SOME STATES IMPOSSIBLE. WE BELIEVE THAT AN AGREEMENT EARLY IN THE TREATMENT PROCESS REGARDING THE USE OF BOARD-CERTIFIED EXPERTS WILL HELP EXPEDITE RESOLUTION OF CONCERNS.
WE COMMIT TO USING ONLY AMERICAN BOARD OF MEDICAL SPECIALISTS (ABMS) BOARD CERTIFIED EXPERT MEDICAL WITNESSES WHO ARE PLASTIC SURGEONS ACTIVELY PRACTICING IN THE STATE OF ARIZONA IN ANY LEGAL SITUATION, WHO FOLLOW THE CODE OF ETHICS OF OUR NATIONAL SPECIALTY SOCIETIES, THE AMERICAN SOCIETY OF PLASTIC SURGEONS AND THE AMERICAN SOCIETY OF AESTHETIC PLASTIC SURGERY.
WE ARE ASKING YOU TO EMPLOY ONLY ABMS BOARD CERTIFIED PHYSICIAN EXPERT PLASTIC SURGERY MEDICAL WITNESSES WHO ARE PLASTIC SURGEONS ACTIVELY PRACTICING IN THE STATE OF ARIZONA IF YOU ARE DISSATISFIED WITH YOUR MEDICAL CARE AND DECIDE TO PURSUE LEGAL ACTION.
WE BELIEVE YOU WILL NEVER HAVE TO CONSIDER THIS AGAIN. BUT IF YOU DO, WE WILL HONOR THIS COMMITMENT TO YOU AS IT IS IN BOTH OF OUR MUTUAL BEST INTERESTS.
FURTHERMORE, SHOULD A MERITORIOUS MEDICAL MALPRACTICE CASE OR CAUSE OF ACTION BE INITIATED OR PURSUED, I AGREE TO USE ABMS BOARD CERTIFIED EXPERT MEDICAL WITNESSES WHO ARE PLASTIC SURGEONS ACTIVELY PRACTICING IN THE STATE OF ARIZONA. FURTHERMORE, I AGREE THAT THESE EXPERT WITNESSES WILL ADHERE TO THE GUIDELINES AND/OR CODE OF CONDUCT DEFINED BY THE SPECIALTY SOCIETIES, THE AMERICAN SOCIETY OF PLASTIC SURGEONS AND THE AMERICAN SOCIETY OF AESTHETIC PLASTIC SURGERY FOR EXPERT WITNESSES.
IN FURTHER CONSIDERATION FOR THIS, I, DR. WILLIAM M. JACOBSEN, AGREE TO THE SAME.
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I agree to use experts licensed and practicing in Arizona. Clear
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Month Day Year
SECTION 5: AUTHORIZATION TO RELEASE MEDICAL RECORDS
I AUTHORIZE ALL HEALTH CARE PROVIDERS & HOSPITALS/INSTITUTIONS TO RELEASE MY MEDICAL RECORDS TO:
FAX: 602.279.1701
WILLIAM M. JACOBSEN, M.D.
COSMETIC & RESTORATIVE SURGERY
2525 EAST ARIZONA BILTMORE CIRCLE, SUITE C236
PHOENIX, AZ 85016
PHONE: 602-212-0100
COMPLETE MEDICAL RECORDS INCLUDING ALL INFORMATION FROM LIST BELOW:
- ALL HOSPITAL AND/OR INSTITUTION RECORDS
- TRANSCRIBED HOSPITAL/INSTITUTION RECORDS (INCLUDES OP NOTES, HISTORY/PHYSICAL EXAMS, CONSULTATIONS, & DISCHARGE SUMMARIES)
- LABORATORY REPORTS
- PATHOLOGY REPORTS
- DIAGNOSTIC IMAGING REPORTS
- EKG/CARDIAC REPORTS
- PHYSICAL/OCCUPATIONAL THERAPY REPORTS
- PHYSICIAN OFFICE/CLINICAL RECORDS
- IMPLANT INFORMATION (INCLUDING OPERATIVE REPORT) PHOTOGRAPHS
- HIV/AIDS/HEPATITIS RECORDS
THIS DOCUMENT MUST BE SIGNED BY THE PATIENT OR PERSON AUTHORIZED BY LAW.
BY SIGNING BELOW, I AUTHORIZE THE RELEASE OF THE ABOVE RECORDS, IF SUCH EXIST:
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I release my medical records for Dr Jacobsen's use in my behalf. Clear
Date
Month Day Year
SECTION 6: PATIENT PRIVACY & COMMUNICATION PRACTICES

WE WANT TO MAKE OUR COMMUNICATION WITH YOU FAST AND EASY BUT FOR YOUR SAFETY DR. JACOBSEN HAS IMPORTANT PRIVACY & COMMUNICATION PRACTICES TO PROTECT YOU!
OUR EMAIL SERVER AND OUR WEBSITE IS HIPAA COMPLIANT! WE PROTECT YOUR DATA!
YOU HAVE REQUESTED THAT DR. JACOBSEN AND HIS STAFF COMMUNICATE WITH YOU BY E-MAIL AND VOICEMAIL. WHILE WE WILL USE EVERY POSSIBLE REASONABLE MEANS TO PROTECT THE SECURITY AND CONFIDENTIALITY OF E-MAILS AND VOICEMAILS SENT AND RECEIVED, WE CANNOT GUARANTEE THE SECURITY AND CONFIDENTIALITY OF ALL E-MAIL AND VOICEMAIL COMMUNICATIONS.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND ACCEPT FOLLOWING PATIENT PRIVACY & E-MAIL COMMUNICATION PRACTICES AND I AM AWARE OF THE RISKS OF USING E-MAIL AND VOICEMAIL AND AGREE TO COMMUNICATE WITH DR. JACOBSEN AND HIS OFFICE IN THIS WAY.
Digital Signature for Section 6 (use your mouse cursor to draw your signature in the space provided).

I understand the below email precations Clear
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DR JACOBSEN WANTS YOU TO BE AWARE OF THE RISKS OF USING E-MAIL
TRANSMITTING YOUR PRIVATE PATIENT INFORMATION BY UNENCRYPTED E-MAIL, VOICE MAIL & TEXT MESSAGING HAS A NUMBER OF RISKS THAT YOU SHOULD CONSIDER. THESE RISKS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:
- EMAIL, VOICE MAIL & TEXT MESSAGING CAN BE CIRCULATED, FORWARDED AND STORED IN NUMEROUS PAPER AND ELECTRONIC FILES.
- E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE IMMEDIATELY BROADCAST WORLDWIDE AND RECEIVED BY MANY INTENDED AND UNINTENDED RECIPIENTS.
- E-MAIL, VOICE MAIL & TEXT MESSAGING SENDERS CAN EASILY MISADDRESS AN E-MAIL.
- E-MAIL, VOICE MAIL & TEXT MESSAGING IS EASIER TO FALSIFY THAN HANDWRITTEN OR SIGNED DOCUMENTS.
- BACKUP COPIES OF E-MAIL, VOICE MAIL & TEXT MESSAGING MAY EXIST EVEN AFTER THE SENDER OR THE RECIPIENT HAS DELETED HIS OR HER COPY.
- MANY EMPLOYERS AND ONLINE SERVICE PROVIDERS HAVE A RIGHT TO ARCHIVE AND INSPECT E-MAILS, VOICE MAIL & TEXT MESSAGING TRANSMITTED THROUGH THEIR SYSTEMS.
- E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE INTERCEPTED, ALTERED, FORWARDED OR USED WITHOUT AUTHORIZATION OR DETECTION.
- E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE USED TO INTRODUCE VIRUSES INTO COMPUTER SYSTEMS.
- E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE USED AS EVIDENCE IN COURT.
- E-MAIL, VOICE MAIL & TEXT MESSAGING CAN BE LOST IN TRANSMISSION.
- E-MAILS, VOICE MAIL & TEXT MESSAGING CAN BE POSTED ON THE INTERNET OR OTHER PUBLICLY AVAILABLE NETWORKS.
E-MAIL COMMUNICATIONS
- IF OTHERS ARE INVOLVED IN YOUR HEALTHCARE, SUCH AS GUARDIANS OR HEALTH CARE AGENTS, YOUR AUTHORIZATION FOR E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS EXTENDS TO THEM, UNLESS YOU TELL US OTHERWISE IN WRITING.
- YOU UNDERSTAND AND AGREE THAT WE CANNOT GUARANTEE THE SECURITY, PRIVACY OR CONFIDENTIALITY OF E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS AND WE WILL NOT BE LIABLE FOR ANY IMPROPER DISCLOSURE OF CONFIDENTIAL INFORMATION, INCLUDING YOUR PATIENT INFORMATION, WHICH IS NOT CAUSED BY OUR INTENTIONAL MISCONDUCT.
- YOU UNDERSTAND AND AGREE THAT ALL E-MAILS, VOICE MAIL & TEXT MESSAGING BETWEEN US MAY BE PRINTED OR DOWNLOADED AND PLACED IN YOUR MEDICAL RECORD AND ANY PERSON AUTHORIZED TO ACCESS YOUR MEDICAL RECORD WILL HAVE ACCESS TO SUCH E-MAILS. YOU ALSO UNDERSTAND AND AGREE THAT WE MAY FORWARD YOUR E-MAILS TO STAFF AND AGENTS AND HEALTH CARE PROVIDERS AS NECESSARY FOR DIAGNOSIS, TREATMENT, REIMBURSEMENT AND OTHER TREATMENT, PAYMENT OR OPERATIONAL PURPOSES.
- E-MAIL, VOICE MAIL & TEXT MESSAGING IS PROVIDED AS A CONVENIENCE, NOT AS A SUBSTITUTE FOR PERSONAL TREATMENT OR OTHER MEDICAL CARE. ALTHOUGH WE WILL ENDEAVOR TO READ AND RESPOND PROMPTLY TO AN E-MAIL, VOICE MAIL & TEXT MESSAGING FROM YOU, WE CANNOT GUARANTEE THAT E-MAILS WILL BE READ AND RESPONDED TO WITHIN ANY PARTICULAR PERIOD OF TIME. IF YOUR E-MAIL, VOICE MAIL & TEXT MESSAGING REQUIRES OR INVITES A RESPONSE FROM US AND YOU HAVE NOT RECEIVED A RESPONSE WITHIN A REASONABLE TIME PERIOD (PLEASE ALLOW FOR AT LEAST 72 HOURS), IT IS YOUR RESPONSIBILITY TO FOLLOW UP TO DETERMINE WHETHER THE INTENDED RECIPIENT RECEIVED THE E-MAIL, VOICE MAIL & TEXT MESSAGING AND WHEN THE RECIPIENT WILL RESPOND. SIMILARLY, IT IS YOUR RESPONSIBILITY TO FOLLOW UP AND/OR SCHEDULE AN APPOINTMENT, IF WARRANTED.
- YOU MAY WITHDRAW YOUR REQUEST ONLY BY WRITTEN NOTICE TO US.
- YOU ARE RESPONSIBLE FOR PROTECTING YOUR PASSWORD OR OTHER MEANS OF ACCESS TO E-MAIL, VOICE MAIL & TEXT MESSAGING. YOU ARE ALSO RESPONSIBLE FOR KNOWING WHO CAN ACCESS YOUR E-MAIL, VOICE MAIL & TEXT MESSAGING ACCOUNT, SUCH AS A SPOUSE OR A FRIEND, AND SHOULD CHOOSE YOUR E-MAIL ACCOUNT ACCORDINGLY. YOU AGREE THAT WE ARE NOT LIABLE FOR BREACHES OF CONFIDENTIALITY CAUSED BY YOU OR ANY THIRD PARTY.
- YOU AGREE TO WAIVE AND RELEASE US AND OUR DIRECTORS, OFFICERS, MEMBERS, MANAGERS, EMPLOYEES, AGENTS, AND REPRESENTATIVES FROM AND AGAINST ANY AND ALL CLAIMS, LIABILITY, DAMAGES, COSTS AND FEES RELATING TO US E-MAILING YOU YOUR INFORMATION, INCLUDING UNAUTHORIZED ACCESS OR OTHER ISSUES THAT MAY ARISE. IN ADDITION, YOU AGREE TO BE BOUND TO THESE GUIDELINES, AS WELL AS ANY OTHER REQUIREMENTS OR GUIDELINES WE MAY PUBLISH RELATING TO E-MAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS.
- YOU AGREE TO LIMIT OR AVOID USING YOUR EMPLOYER’S COMPUTER OR OTHER COMPUTERS THAT ARE NOT UNDER YOUR CONTROL, SUCH AS THOSE PROVIDED AT INTERNET CAFÉS OR LIBRARIES.
- YOU AGREE TO PROMPTLY INFORM US IN WRITING OF CHANGES IN YOUR E-MAIL ADDRESS, VOICE MAIL NUMBER & TEXT MESSAGING NUMBER. WE ARE NOT RESPONSIBLE FOR E-MAILS TO A PRIOR ADDRESS IF WE HAVE NOT BEEN ADVISED OF THE CHANGE IN WRITING.
- YOU AGREE TO PUT YOUR NAME IN THE BODY OF AN E-MAIL, VOICE MAIL & TEXT MESSAGING TO US SO WE KNOW WHO IS SENDING IT.
- YOU AGREE TO INCLUDE THE CATEGORY OF THE COMMUNICATION IN THE E- SUBJECT LINE OF AN EMAIL TO US FOR ROUTING PURPOSES (SUCH AS “BILLING QUESTION”, “PRESCRIPTION INFORMATION”, “MEDICAL ADVICE”).
- YOU AGREE TO REVIEW AN E-MAIL, VOICE MAIL & TEXT MESSAGING TO US TO MAKE SURE IT IS CLEAR AND THAT ALL RELEVANT INFORMATION IS PROVIDED BEFORE SENDING IT.
- YOU AGREE TO MAKE SURE THAT OUR E-MAIL, VOICE MAIL & TEXT MESSAGING ADDRESS IS CORRECT BEFORE SENDING AN E-MAIL TO US.
- YOU AGREE TO SEND US A REPLY MESSAGE OR DELIVERY RECEIPT WHEN WE SEND YOU AN E-MAIL, VOICE MAIL & TEXT MESSAGING SO WE KNOW YOU HAVE RECEIVED IT.
- YOU AGREE TO TAKE PRECAUTIONS TO PRESERVE THE CONFIDENTIALITY OF OUT E-MAILS, VOICE MAIL & TEXT MESSAGING, SUCH AS USING SCREEN SAVERS AND SAFEGUARDING YOUR COMPUTER PASSWORD.
- YOU AGREE TO ABIDE BY ALL OF THE ABOVE DURING YOUR EMAIL, VOICE MAIL & TEXT MESSAGING COMMUNICATIONS WITH US.
RECOMMENDATIONS
- IN ORDER TO HELP PROTECT YOUR COMPUTER AGAINST MALICIOUS SOFTWARE AND SAFEGUARD YOUR INFORMATION, SOFTWARE AND SYSTEM COMMUNICATIONS WE RECOMMEND YOU INSTALL AND REGULARLY UPDATE PROTECTIVE SOFTWARE, SUCH AS FIREWALL, ANTI-VIRUS AND ANTI-SPYWARE PROGRAMS.
- IN ORDER TO HELP REDUCE THE THREAT OF PEOPLE INAPPROPRIATELY INTERCEPTING AND READING YOUR E-MAILS, VOICE MAIL & TEXT MESSAGING, WE RECOMMEND YOU USE SOFTWARE TO ENCRYPT YOUR E-MAILS THAT CONTAIN INFORMATION YOU DETERMINE TO BE CONFIDENTIAL
PATIENT PRIVACY
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.
WILLIAM M. JACOBSEN, MD, P.C. IS DEDICATED TO MAINTAINING THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION. EACH TIME A PATIENT VISITS THIS OFFICE, A RECORD IS MADE THAT DESCRIBES THE TREATMENTS AND SERVICES PROVIDED. FEDERAL LAW OUTLINES SPECIFIC PRIVACY PROTECTIONS AND INDIVIDUAL RIGHTS RELATED TO THE INFORMATION WE MAINTAIN THAT IDENTIFIES YOU AS A PATIENT. PROTECTED INFORMATION INCLUDES DEMOGRAPHIC DATA AND FACTS ABOUT YOUR PAST, PRESENT, OR FUTURE PHYSICAL OR MENTAL HEALTH. OUR OFFICE HAS PUT IN PLACE POLICIES AND PROCEDURES TO HELP PROTECT YOUR HEALTH INFORMATION. WE ARE REQUIRED TO PROVIDE THIS NOTICE OUTLINING OUR LEGAL DUTIES AND RESPONSIBILITIES RELATED TO THE USE AND DISCLOSURE OF PATIENT IDENTIFIABLE HEALTH INFORMATION, PRIVACY PRACTICES, AND EXAMPLES OF HOW YOUR INFORMATION MAY BE USED OR DISCLOSED.
OUR PRACTICE WILL ABIDE BY THE TERMS OF THIS NOTICE. WE MAY REVISE THIS NOTICE AT ANY TIME. THE NEW NOTICE WILL BE POSTED IN OUR OFFICE IN A PROMINENT LOCATION. YOU CAN REQUEST A COPY OF OUR MOST CURRENT NOTICE AT ANY TIME. REVISIONS TO THE NOTICE WILL BE EFFECTIVE FOR ALL HEALTH CARE INFORMATION THIS OFFICE MAINTAINS: PAST, PRESENT, OR FUTURE.
PRACTICE MAY USE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION FOR THE FOLLOWING PURPOSES WITHOUT YOUR AUTHORIZATION:
1. TREATMENT: WE MAY USE AND DISCLOSE YOUR IDENTIFIABLE HEALTH INFORMATION TO TREAT YOU AND ASSIST OTHERS IN YOUR TREATMENT. FOR INSTANCE, WE MAY SEND A COPY OF YOUR RECORDS TO ANOTHER DOCTOR SO THAT YOU CAN BE EVALUATED FOR A SPECIFIC CONDITION, OR WE MAY DISCLOSE INFORMATION TO OTHERS WHO TAKE PART IN YOUR CARE, SUCH AS YOUR SPOUSE, CHILDREN, OR PARENTS.
2. PAYMENT: WE MAY USE YOUR HEALTH INFORMATION TO BILL AND COLLECT PAYMENT FOR SERVICES PROVIDED. THIS MAY INCLUDE PROVIDING YOUR INSURANCE COMPANY WITH THE DETAILS OF YOUR TREATMENT, SHARING YOUR PAYMENT INFORMATION WITH OTHER TREATMENT PROVIDERS, CONTACTING YOU OVER THE PHONE OR THROUGH THE MAIL ABOUT BALANCES, OR SENDING UNPAID BALANCES TO A COLLECTION AGENCY.
3. HEALTH CARE OPERATIONS: WE MAY USE AND DISCLOSE HEALTH INFORMATION TO OPERATE OUR BUSINESS. FOR EXAMPLE, YOUR HEALTH INFORMATION MAY BE USED TO EVALUATE THE QUALITY OF CARE WE PROVIDE, FOR STATE LICENSING, OR TO IDENTIFY YOU BY NAME WHEN YOU VISIT THE OFFICE.
4. APPOINTMENT REMINDERS: WE MAY USE AND DISCLOSE YOUR INFORMATION TO REMIND YOU OF APPOINTMENTS. WE MAY ALSO MAIL YOU A REMINDER FOR FOLLOW-UP VISITS.
5. TREATMENT OPTIONS: WE MAY USE YOUR HEALTH INFORMATION TO INFORM YOU OF TREATMENT OPTIONS OR OTHER HEALTH-RELATED SERVICES WE OFFER THAT MAY BE OF INTEREST TO YOU.
6. BUSINESS ASSOCIATES: WE MAY SHARE YOUR HEALTH INFORMATION WITH OTHER INDIVIDUALS OR COMPANIES THAT PERFORM VARIOUS ACTIVITIES FOR, OR ON BEHALF OF, OUR OFFICE SUCH AS AFTER-HOURS TELEPHONE ANSWERING, BILLING, OR QUALITY ASSURANCE. OUR BUSINESS ASSOCIATES AGREE TO PROTECT THE PRIVACY OF YOUR INFORMATION.
PRACTICE MAY DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION WHEN PERMITTED OR REQUIRED TO BY LAW, INCLUDING:
§ FOR PUBLIC HEALTH ACTIVITIES INCLUDING REPORTING OF CERTAIN COMMUNICABLE DISEASES.
§ FOR WORKERS’ COMPENSATION OR SIMILAR PROGRAMS AS REQUIRED BY LAW.
§ FOR PRODUCT RECALLS
§ TO REPORT ADVERSE REACTIONS TO MEDICATIONS
§ TO AUTHORITIES WHEN WE SUSPECT ABUSE, NEGLECT, OR DOMESTIC VIOLENCE.
§ TO HEALTH OVERSIGHT AGENCIES.
§ FOR CERTAIN JUDICIAL AND ADMINISTRATIVE PROCEEDINGS PURSUANT TO AN ADMINISTRATIVE ORDER.
§ FOR LAW ENFORCEMENT PURPOSES.
§ TO A MEDICAL EXAMINER, CORONER, OR FUNERAL DIRECTOR.
§ FOR THE FACILITATION OF ORGAN, EYE, OR TISSUE DONATION IF YOU ARE AN ORGAN DONOR.
§ FOR RESEARCH PURPOSES UNDER STRICTLY LIMITED CIRCUMSTANCES.
§ TO AVERT A SERIOUS THREAT TO YOUR HEALTH AND SAFETY OR THAT OF OTHERS.
§ FOR GOVERNMENTAL PURPOSES, SUCH AS MILITARY SERVICE OR FOR NATIONAL SECURITY.
§ IN THE EVENT OF AN EMERGENCY OR FOR DISASTER RELIEF.
§ FOR A HOSPITAL DIRECTORY
§ TO PROVIDE MENTAL HEALTH CARE SERVICES WITH YOUR PRIOR WRITTEN PERMISSION.
§ TO MARKET OUR SERVICES AND SELL YOUR INFORMATION WITH YOUR PRIOR WRITTEN PERMISSION.
§ TO RAISE FUNDS, BUT AFTER THE FIRST CONTACT YOU CAN REQUEST THAT WE NOT CONTACT YOU AGAIN.
§ IN ANY OTHER INSTANCE REQUIRED BY LAW.
§ IN BILLING DISPUTE WITH CREDIT CARD COMPANIES, MERCHANTS OR BANK TO DISCREETLY COORBORATE SERVICES RECEIVED BY YOU
IF YOU ARE NOT ABLE TO TELL US YOUR PREFERENCE, FOR EXAMPLE, IF YOU ARE UNCONSCIOUS, PRACTICE MAY GO AHEAD AND SHARE YOUR INFORMATION IF WE BELIEVE IT IS IN YOUR BEST INTEREST. PRACTICE MAY ALSO DISCLOSE YOUR INFORMATION TO FAMILY MEMBERS AND/OR OTHER PERSONS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. PRACTICE MAY LEAVE MESSAGES FOR YOU AT HOME OR WORK ABOUT YOUR VISITS OR TEST RESULTS. IF YOU DO NOT WANT US TO DO SO, PLEASE INFORM OUR OFFICE IN WRITING.
ALL OTHER USES AND DISCLOSURES OF YOUR INFORMATION TO OTHERS WILL REQUIRE A WRITTEN, SIGNED AUTHORIZATION FROM YOU. YOU HAVE THE RIGHT TO REVOKE YOUR AUTHORIZATION AT ANY TIME EXCEPT TO THE EXTENT THAT WE HAVE ALREADY ACTED ON IT. SHOULD YOU REQUIRE YOUR RECORDS TO BE RELEASED, PRACTICE WILL PROVIDE YOU WITH AN AUTHORIZATION FORM TO COMPLETE AND RETURN TO THE ADDRESS LISTED ON IT.
YOUR HEALTH RECORD IS THE PHYSICAL PROPERTY OF PRACTICE. THE INFORMATION CONTAINED IN IT BELONGS TO YOU. BELOW IS A LIST OF YOUR RIGHTS REGARDING INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. ALL REQUESTS RELATED TO THESE ITEMS MUST BE MADE IN WRITING TO OUR PRIVACY OFFICER AT THE ADDRESS LISTED BELOW. WE WILL PROVIDE YOU WITH APPROPRIATE FORMS TO EXERCISE THESE RIGHTS. WE WILL NOTIFY YOU, IN WRITING, IF YOUR REQUESTS CANNOT BE GRANTED.
1. RESTRICTIONS ON USE AND DISCLOSURE: YOU HAVE THE RIGHT TO REQUEST RESTRICTIONS ON HOW WE USE AND DISCLOSE YOUR HEALTH INFORMATION. THIS INCLUDES REQUESTS TO RESTRICT DISCLOSURE OF YOUR HEALTH INFORMATION TO ONLY CERTAIN INDIVIDUALS, OR ENTITIES, INVOLVED IN YOUR CARE SUCH AS FAMILY MEMBERS AND INSURANCE COMPANIES. WE ARE NOT REQUIRED TO AGREE WITH YOUR REQUEST. IF WE AGREE, WE ARE BOUND TO THE AGREEMENT UNLESS DISCLOSURE IS OTHERWISE REQUIRED OR AUTHORIZED BY LAW. IF YOU PAY FOR A SERVICE OR HEALTH CARE ITEM OUT-OF-POCKET IN FULL, YOU CAN ASK US NOT TO SHARE THAT INFORMATION FOR THE PURPOSE OF PAYMENT OR OUR OPERATIONS WITH YOUR HEALTH INSURER. WE WILL SAY “YES” UNLESS A LAW REQUIRES US TO SHARE THAT INFORMATION.
2. CONFIDENTIAL COMMUNICATIONS: YOU HAVE THE RIGHT TO REQUEST THAT WE COMMUNICATE WITH YOU OR SOMEONE YOU CHOOSE TO ACT FOR YOU IN A PARTICULAR MANNER OR AT A CERTAIN LOCATION. FOR EXAMPLE, YOU MAY REQUEST THAT WE ONLY CONTACT YOU AT HOME. WE WILL ACCOMMODATE REASONABLE REQUESTS. IF YOU HAVE GIVEN SOMEONE MEDICAL POWER OF ATTORNEY OR IF SOMEONE IS YOUR LEGAL GUARDIAN, THAT PERSON CAN EXERCISE YOUR RIGHTS AND MAKE CHOICES ABOUT YOUR HEALTH INFORMATION. WE WILL MAKE SURE THE PERSON HAS THIS AUTHORITY AND CAN ACT FOR YOU BEFORE WE TAKE ANY ACTION.
3. ACCESS: YOU HAVE THE RIGHT TO INSPECT OR REQUEST A COPY OF RECORDS USED TO MAKE DECISIONS ABOUT YOUR HEALTH CARE, INCLUDING YOUR MEDICAL CHART AND BILLING RECORDS. THIS OFFICE WILL SCHEDULE APPOINTMENTS FOR RECORD INSPECTION. WE MAY CHARGE A FEE FOR PROVIDING YOU COPIES OF YOUR RECORDS. UNDER SPECIAL CIRCUMSTANCES, WE MAY DENY YOUR REQUEST TO INSPECT AND/OR COPY YOUR RECORDS. YOU MAY REQUEST A REVIEW OF THIS DENIAL. YOU MAY ALSO REQUEST AN ELECTRONIC COPY OF YOUR RECORDS BE PROVIDED. THIS ELECTRONIC COPY MAY BE SENT USING E-MAIL TO YOUR SPECIFIED ADDRESS, CD FOR FLASH DRIVE. PLEASE NOTE THAT E-MAIL COMMUNICATIONS ARE NOT A SECURE METHOD FOR TRANSPORT.
4. RECORD AMENDMENT: YOU HAVE THE RIGHT TO REQUEST AMENDMENTS TO YOUR HEALTH RECORDS CREATED BY AND FOR THIS PRACTICE IF YOU FEEL THEY ARE INCORRECT OR INCOMPLETE. WE MAY ACCEPT OR DENY YOUR REQUEST. IF WE DENY YOUR REQUEST, YOU HAVE THE RIGHT TO PROVIDE A STATEMENT OF DISAGREEMENT.
5. ACCOUNTING OF DISCLOSURES: YOU HAVE THE RIGHT TO RECEIVE AN ACCOUNTING OF DISCLOSURES. THIS MEANS YOU MAY REQUEST A LIST OF CERTAIN DISCLOSURES PRACTICE HAS MADE OF YOUR RECORDS. UPON YOUR REQUEST, WE WILL PROVIDE THIS INFORMATION TO YOU ONE TIME FREE DURING EACH TWELVE (12) MONTH PERIOD. THERE MAY BE A FEE FOR ADDITIONAL COPIES.
6. COPY OF NOTICE: YOU HAVE THE RIGHT TO REQUEST THAT WE PROVIDE YOU WITH A PAPER COPY OF THIS NOTICE OF PRIVACY PRACTICES.
WHEN FEDERAL AND STATE PRIVACY LAWS DIFFER, AND STATE LAW IS MORE PROTECTIVE OF YOUR INFORMATION OR PROVIDES YOU WITH GREATER ACCESS TO YOUR INFORMATION, STATE LAW MAY OVERRIDE FEDERAL LAW.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRACTICE’S PRIVACY OFFICER AT (602) 212-0100. IF YOU FEEL YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU HAVE THE RIGHT TO FILE A WRITTEN COMPLAINT WITH OUR OFFICE. YOU MAY ALSO FILE A COMPLAINT WITH THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS BY SENDING A LETTER TO 200 INDEPENDENCE AVENUE, S.W., WASHINGTON, D.C 20201 OR CALLING 1-877-696-6775, OR VISITING: WWW.HHS.GOV/OCR/PRIVACY/HIPAA/COMPLAINTS/
THERE WILL BE NO RETALIATION FOR FILING A COMPLAINT.
FOR MORE INFORMATION SEE: WWW.HHS.GOV/OCR/PRIVACY/HIPAA/UNDERSTANDING/CONSUMERS/NOTICEPP.HTML
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SECTION 7: INSURANCE NON-PAYMENT
PLEASE BE AWARE THAT YOUR INSURANCE PROVIDER MAY DENY YOUR COVERAGE FOR YOUR SURGERY. THIS MAY BE DENIED FOR NON-COVERED SERVICES, COSMETIC OR UNNECESSARY SURGERY DEFINED IN A VARIETY O FWAYS BY YOUR INSURER. THIS CAN OCCUR EVEN IF YOUR SURGERY WAS APPROVED OR AUTHORIZED AHEAD OF TIME AND EVEN IF YOU THOUGHT IT WAS NECESSARY AND DR JACOBSEN FELT THE SURGERY WAS NECESSARY. WE DO EVERYTHING WE CAN TO APPEAL ON YOUR BEHALF FOR 90 DAYS, HOWEVER. IN RARE CASES, YOU MAY BE RESPONSIBLE FOR YOUR SURGICAL FEES IF YOUR INSURANCE PROVIDER FAILS TO COVER YOU FOR ANY REASON.
PLEASE SIGN BELOW THAT YOU UNDERSTAND THIS RESPONSIBILITY. THANK YOU, DR. JACOBSEN & STAFF.
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SECTION 8: PRIVACY NON-PAYMENT POLICY
PLEASE BE AWARE THAT IF YOU RECEIVE SERVICES AND THERE EXISTS A PAYMENT DISPUTE FROM A SOURCE SUCH AS A CREDIT CARD MERCHANT OR A BANKING ENTITY DR JACOBSEN WILL DISCRETELY USE YOUR PRIVATE HEALTH INFORMATION TO COORBORATE THE SERVICE YOU RECEIVED IF REQUIRED BY YOUR PAYMENT SOURCE. DR JACOBSEN RECOMMENDS YOU KEEP YOUR PAYMENT SOURCES PRIVATE SO YOUR HEALTH INFORMATION WILL REMAIN ENTIRELYPRIVATE AS WELL. CASH, CASHIERS CHECKS AND PERSONAL CHECKS ARE THE MOST PRIVATE SOURCES OF PAYMENT FOR
YOU.
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SECTION 9 CREDIT CARD FEES
CREDIT CARD FEES ARE UNFORTUNATELY EXPENSIVE! IF YOU CHOOSE TO USE YOUR CREDIT OR DEBIT CARD WE WELCOME THESE PAYMENT METHODS BUT THE FEES WILL BE ADDED TO YOUR PAYMENT! 2.5% FOR CARD PRESENT IN OFFICE AND 3.5% FRO CARD NOT PRESENT OR REMOTE CHARGES + $0.15/TRANSACTION FEE. CASH AND CHECKS HAVE NO ADDITION FEES..
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CLICK "AGREE & SUBMIT" TO SUBMIT THIS FORM AFTER READING BELOW
By submitting this form, I agree to all conditions and certify that I have read it, and understand it, in its entirety. I also understand that I have the alternative option to fill this form out in-person at Dr. Jacobsen's office. A copy will be emailed to you. Note if this online submission form is incomplete you will be able to complete it in the office once you arrive.
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Patient Registration Form

SECTION 9 CREDIT CARD FEES

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