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The physicians and nurse practitioners at Four Rivers Internal Medicine, PLLC encourage respect for the personal preferences and values of each individual. We consider you a partner in your medical care. When you are well informed, participate in treatment decisions and communicate openly with your doctor and nurse, you help make your care as effective as possible.  I understand that as part of my health care, Four Rivers Internal Medicine, PLLC originate and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans of future care or treatment. I understand that this information serves as: a basis of my care and treatment, a means of communication with my other health care professionals, a source of information for submitting medical claims for payment and a means by which a payer can verify services rendered. I understand that Four Rivers InternalMedicine, PLLC is not required to agree to any restrictions requested and I may revoke this consent in writing. Such revocation will not apply to authorized uses and disclosures made prior to the revocation. I also understand that by refusing to approve this consent or revoking this consent, this practice may refuse to treatment me as permitted by section 164.506 of the Code of Federal Regulations. I understand that Four Rivers Internal Medicine, PLLC reserves the right to change the notice and practices at any time. Should the notice be changed, the practice will post a copy of revised notice visible to all in the office. I understand health information may be used or disclosed by mail, email, telephone, other electronic means and by fax. The medical practice assumes that each patient has a mutually supportive communicative family. Unless otherwise directed, I authorize the use or disclosure of my health information for purposes of treatment, payment or healthcare operations to family or other healthcare professionals involved in my care or treatment, insurance and third party payers and pharmacies. It is acknowledged that I am an integral partner in my health care team. As part of this team, I will assist the office and proactively provide a list of people or entities to whom I do not wish medical information to be released. I will also provide the medical office a constantly updated list of contact people addresses, phone numbers, cell phones, work numbers and email addresses through which I may be contacted. I understand that should I have an emergent situation and the medical office cannot easily contact me, I may be at risk of untoward problems.  When you are a partner at Four Rivers Internal Medicine, PLLC, you have a right to:  * Receive fair and compassionate care at all times and under all circumstances.  * Be treated equally and receive the same level of care regardless of your race, sex, religion, age or disability.  * Retain your personal dignity and privacy; receive care sensitive to your personal feelings and need for bodily privacy, receive care in a safe setting, and to be free from abuse and harassment.  * Have family members and representatives of your choice informed of your condition.  * Receive personal treatment, through an individual treatment plan administered by our qualified and experienced staff and to participate in the development and implementation of your treatment plan. We value each patient’s cultural, racial and religious heritage as part of your treatment plan.  * Maintain the confidentiality of your medical records and to access information contained in your record within a reasonable timeframe.  * Examine and receive an explanation of your bill. * Be informed of practice rules and regulations that affect your activities and behavior as a patient.  * Formulate advance directives (living will, durable power of attorney, healthcare surrogate, etc.) and to comply with these directives in accordance with federal and state laws. We encourage you to ensure that all financial and advance directives are completed in a timely manner and that the clinic receives a copy of your written wishes that affect your care.  * Be free from sedation and restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation.


The patient and/or their designated surrogate(s) have the right to: 

* Be informed of your rights before the furnishing or discontinuance of care, whenever possible. 
* Make informed decisions regarding your care, including being informed of your health status, involved in care planning and treatment, able to request or refuse treatment to the extent permitted by law, and to be told of the medical consequences of your actions. 
* Refuse to participate in clinical training or be used in the gathering of data for research purposes, regardless of your payment source – government, personal, charity or third party. 
* Know the identity of the doctor/caregiver responsible for your primary care. 
* Be told of any medical procedures and tests that are to be carried out, the reason for the procedure or tests, and the identity of those who will be performing them, if known. 
* Expect reasonable continuity of care to assure that you are advised of your outpatient care options, requirements and of your follow-up care needs. 
* Communicate problems or concerns to 3131 Parisa Drive, Paducah KY 42003; Phone (270) 444-8000. When you are a patient, you are responsible for: 
* Providing to the best of your knowledge, accurate and complete information about your health history including present compliant, all past illnesses, hospital stays, use of all medications and substances and other pertinent matters relating to your health.

* Asking questions when you do not understand information or instructions. 

* Reporting unexpected changes in your condition to your physician.

* Understanding the instructions for your on-going treatment. The patient/responsible party is responsible for scheduling and keeping all appointments for lab, imaging studies, consultations and procedures. If you believe you cannot follow through with your evaluation and or treatment, you are responsible for telling your doctor and bringing a responsible party with you. 

* Showing consideration for the needs of other patients, staff members and physicians involved with your care and assisting with the control of noise, odors, smoking and number of visitors. 
* Following any rules and regulations associated with your illness including safety and infection control. 
* Providing information regarding your insurance the medical office, hospital and laboratory to arrange payment for services. I agree to promptly pay for services rendered. 
* Making decisions in my daily life and dealing with the effects of those decisions on my personal health. As I am my own patient, I am responsible for my own health decisions. 
* I agree that should I inadvertently cause damage to any part of the clinic, I agree to be responsible for charges for the repair or replacement of the item. 
* Arranging for any advance directives (living will, durable power of attorney, healthcare surrogate, etc.) and communicating these advance directives to your health care provider, hospital and ambulance service. 

* Understanding that the physician may utilize or recommend treatment based on current medical knowledge not necessarily accepted by all. 
* Communicating any problems or concerns relating to your care to the doctor or health care provider. 
* Calling the office for test reports if the office has not contacted me within a 2 week period of time of the testing date. I realize that people and electronics are not foolproof and the office may not have received a report. I understand a routine call 2 weeks after I have not received a report provides a safety net for me. I understand it is the patient’s responsibility to provide this safety net. 
* Agreeing to communicate any special instructions, especially insurance requirements to the nursing staff. This also occurs when you have imaging procedures, blood work or special samples requiring laboratory or pathology evaluation or referral to consultants. The patient is responsible for insuring that all diagnostics are arranged according to his/her insurance specifications. Each patient is required to provide the office with an updated copy of your medical insurance benefits policy and notify the office of any pre-certification requirements. Without such, the office cannot properly complete needed pre-certification. I will relay and report any special medication allowances as provided for or allowed by my insurance carrier. 
* I realize my medical records are the property of the clinic and may be kept in a paper or digital form on or off clinic property. I realize that with the use of a federally mandated electronic health record, electronic errors, including diagnoses, can be made and I will cooperate to ensure my record is accurate to my condition. 
* I understand that if I am referred to another physician, consultant or medical provider, all required diagnostic studies and future diagnostic studies and monitoring involving the specialty of the referral medical provider is, and, and will be, the responsibility of the consultant medical provider and Four Rivers Internal Medicine, PLLC will not provide that current or future diagnostics or therapeutic interventions referable to that medical specialty. I understand that it is my responsibility to ensure that I have assessment and follow-up by the consulting provider. 
* I understand that the medical providers and staff of Four Rivers Internal Medicine, PLLC personally or electronically sign many medical reports. It is understood that the affixation of a signature to a report indicates that the provider or staff acknowledges receipt of the report only, and does not indicate review of the report contents. 
* The clinic provides care for two designations of patients. The first designation consists of our private patients of whom we provide a comprehensive level of care on an ongoing basis. The second designation consists of our walk-in patients of whom we are happy to provide immediate care for a presenting symptom(s), but not a comprehensive level of care. A medical assessment for a walk in patient would not be expected to assess a patient for a possible, even significant, underlying disease process. Our walk-in patients are welcome to become regular private patients after a comprehensive exam and medical assessment by our staff. 
* If my health declines and I am no longer able to properly care for my needs, I agree to arrange for and or allow a health care surrogate to assist in my care, including safely driving and escorting me to and from all appointments and required activities of daily living. 
* I agree not to use any tobacco products or controlled substances on or near the campus of Four Rivers Internal Medicine, PLLC. 

* I understand that any form produced outside or inside the medical office requiring the review and signature of the health care provider, may be subject to a review/completion charge by the health care provider. 
* As part of the medical encounter, the provider may review medical concerns and items not directly expressed during the exam but may be part of the patient’s clinical presentation and follow-up. 
* I agree to use no more than two local pharmacies for my medications and should I use a mail order pharmacy, I agree to keep the clinic informed of that pharmacy’s dispensing requirements. I agree to use only one supplier for durable/dispensible health products such as diabetic supplies and that the supplier’s name must be presented to the clinic in writing and approved by the clinic health care provider. 
* I agree to bring the all dispensed bottles of medications I have with me to every appointment, no matter who prescribed the medication for me. 
* I understand that the health care documents produced by my health care provider consists of information gathered from the patient at the visit, the prior chart record, the provider’s short and long term knowledge of the patient and other sources such as the internet, hospital records and forwarded written and verbal records from other providers. 
* I agree that my health care is a partnership, a shared responsibility among many parties and I agree to participate in my care.

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